Healthcare Provider Details

I. General information

NPI: 1285139170
Provider Name (Legal Business Name): SHAWN TAHATA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2018
Last Update Date: 09/16/2023
Certification Date: 09/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3250 GEARY BLVD FL 3
SAN FRANCISCO CA
94118-3319
US

IV. Provider business mailing address

3250 GEARY BLVD FL 3
SAN FRANCISCO CA
94118-3319
US

V. Phone/Fax

Practice location:
  • Phone: 415-833-2998
  • Fax: 415-833-2999
Mailing address:
  • Phone: 415-833-2998
  • Fax: 415-833-2999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number29219
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number66118
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number174662A
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: