Healthcare Provider Details

I. General information

NPI: 1073541199
Provider Name (Legal Business Name): IDA JAHED MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 12/15/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5555 MONTGOMERY DR
SANTA ROSA CA
95409-8846
US

IV. Provider business mailing address

3908 MILLBROOK DR
SANTA ROSA CA
95404-7613
US

V. Phone/Fax

Practice location:
  • Phone: 707-538-8400
  • Fax:
Mailing address:
  • Phone: 216-386-7221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number087336
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number35-087336
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: