Provider Demographics
NPI:1063434900
Name:SOMA MEDICAL GROUP
Entity type:Organization
Organization Name:SOMA MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SOHAIL
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVOUDIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-214-1000
Mailing Address - Street 1:PO BOX 5090
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90278-9290
Mailing Address - Country:US
Mailing Address - Phone:310-214-1000
Mailing Address - Fax:310-214-8540
Practice Address - Street 1:1959 KINGSDALE AVE
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90278-3417
Practice Address - Country:US
Practice Address - Phone:310-214-1000
Practice Address - Fax:310-214-8540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2008-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA44878207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0059090Medicaid
CAW12290Medicare ID - Type Unspecified
CAGR0059090Medicaid