MEDICARE: DR. SIRPA A TAVAKOLI M.D.

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	2084P0800X	Psychiatry Physician	MD25061	OR
2	2084P0800X	Psychiatry Physician	A87373	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	:	1326016296
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SIRPA A TAVAKOLI M.D.

Provider Business Mailing Address
First Line	:	1743 SYCAMORE AVE
Second Line	:
City	:	KINGMAN
State	:	AZ
Zip	:	86409-0927
Country	:	US
Telephone Number	:	928-757-8111
Fax Number	:

Provider Business Practice Location Address
First Line	:	1743 SYCAMORE AVE
Second Line	:
City	:	KINGMAN
State	:	AZ
Zip	:	86409-0927
Country	:	US
Telephone Number	:	928-757-8111
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/08/2006
Last Update Date	:	01/21/2011

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