Healthcare Provider Details

I. General information

NPI: 1194641084
Provider Name (Legal Business Name): SOPHIE QAJARI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2026
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH ST # BI2144
AUGUSTA GA
30912-0004
US

IV. Provider business mailing address

3601 W HIDDEN LN UNIT 101
ROLLING HILLS ESTATES CA
90274-4105
US

V. Phone/Fax

Practice location:
  • Phone: 762-375-5836
  • Fax:
Mailing address:
  • Phone: 424-305-8639
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number114043
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: