Healthcare Provider Details

I. General information

NPI: 1942543681
Provider Name (Legal Business Name): NAVID POURTAHERI M.D., PH.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2013
Last Update Date: 04/06/2021
Certification Date: 04/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

490 POST ST STE 1701
SAN FRANCISCO CA
94102-1308
US

IV. Provider business mailing address

530 DIVISADERO ST. PMB 759
SAN FRANCISCO CA
94117-2213
US

V. Phone/Fax

Practice location:
  • Phone: 415-523-5235
  • Fax: 415-523-5235
Mailing address:
  • Phone: 415-523-5235
  • Fax: 415-523-5235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number01083848A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code2082S0099X
TaxonomyPlastic Surgery Within the Head and Neck (Plastic Surgery) Physician
License Number01083848A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number1.062965
License Number StateCT
# 4
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberA167926
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: