MEDICARE: SOMA MEDICAL GROUP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	A44878	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063434900
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOMA MEDICAL GROUP

Provider Business Mailing Address
First Line	:	PO BOX 5090
Second Line	:
City	:	REDONDO BEACH
State	:	CA
Zip	:	90278-9290
Country	:	US
Telephone Number	:	310-214-1000
Fax Number	:	310-214-8540

Provider Business Practice Location Address
First Line	:	1959 KINGSDALE AVE
Second Line	:
City	:	REDONDO BEACH
State	:	CA
Zip	:	90278-3417
Country	:	US
Telephone Number	:	310-214-1000
Fax Number	:	310-214-8540

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	SOHAIL DAVOUDIAN
Credential	:	M.D.
Telephone Number	:	310-214-1000

Provider Enumeration Date	:	07/23/2006
Last Update Date	:	12/04/2008

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Directions to “SOMA MEDICAL GROUP ” Practice Location

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