Healthcare Provider Details

I. General information

NPI: 1174920771
Provider Name (Legal Business Name): IDA JAHED, MD, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2014
Last Update Date: 11/25/2014
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 TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: IDA JAHED
Title or Position: SOLE MANAGER
Credential: MD
Phone: 216-386-7221