Provider Demographics
NPI:1124253257
Name:SODDY DAISY PEDIATRICS
Entity type:Organization
Organization Name:SODDY DAISY PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAHLA
Authorized Official - Middle Name:A
Authorized Official - Last Name:KAUKAB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-451-0622
Mailing Address - Street 1:8804 DAYTON PIKE STE F
Mailing Address - Street 2:
Mailing Address - City:SODDY DAISY
Mailing Address - State:TN
Mailing Address - Zip Code:37379-4306
Mailing Address - Country:US
Mailing Address - Phone:423-451-0622
Mailing Address - Fax:423-451-0624
Practice Address - Street 1:8804 DAYTON PIKE STE F
Practice Address - Street 2:
Practice Address - City:SODDY DAISY
Practice Address - State:TN
Practice Address - Zip Code:37379-4306
Practice Address - Country:US
Practice Address - Phone:423-451-0622
Practice Address - Fax:423-451-0624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-19
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN37633208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3804863Medicaid
TN3887638Medicaid