MEDICARE: AZITA TAGHAVY - A PROFESSIONAL CORP

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

General Provider Information

NPI Number	:	1205406477
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AZITA TAGHAVY - A PROFESSIONAL CORP

Provider Business Mailing Address
First Line	:	21 TAMAL VISTA BLVD STE 110
Second Line	:
City	:	CORTE MADERA
State	:	CA
Zip	:	94925-1122
Country	:	US
Telephone Number	:	415-924-5010
Fax Number	:	415-924-5210

Provider Business Practice Location Address
First Line	:	21 TAMAL VISTA BLVD STE 110
Second Line	:
City	:	CORTE MADERA
State	:	CA
Zip	:	94925-1122
Country	:	US
Telephone Number	:	415-924-5010
Fax Number	:	415-924-5210

Authorized Official
Title or Position	:	PRESIDENT
Name	:	AZITA TAGHAVY
Credential	:	MD
Telephone Number	:	415-924-5010

Provider Enumeration Date	:	06/29/2021
Last Update Date	:	07/22/2021

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