Healthcare Provider Details

I. General information

NPI: 1124253257
Provider Name (Legal Business Name): SODDY DAISY PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2009
Last Update Date: 05/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8804 DAYTON PIKE STE F
SODDY DAISY TN
37379-4306
US

IV. Provider business mailing address

8804 DAYTON PIKE STE F
SODDY DAISY TN
37379-4306
US

V. Phone/Fax

Practice location:
  • Phone: 423-451-0622
  • Fax: 423-451-0624
Mailing address:
  • Phone: 423-451-0622
  • Fax: 423-451-0624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number37633
License Number StateTN

VIII. Authorized Official

Name: DR. SHAHLA A KAUKAB
Title or Position: OWNER
Credential: M.D.
Phone: 423-451-0622