Provider Demographics
NPI:1285139170
Name:TAHATA, SHAWN (MD)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:
Last Name:TAHATA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3250 GEARY BLVD FL 3
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94118-3319
Mailing Address - Country:US
Mailing Address - Phone:415-833-2998
Mailing Address - Fax:415-833-2999
Practice Address - Street 1:3250 GEARY BLVD FL 3
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94118-3319
Practice Address - Country:US
Practice Address - Phone:415-833-2998
Practice Address - Fax:415-833-2999
Is Sole Proprietor?:No
Enumeration Date:2018-03-24
Last Update Date:2023-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN29219207R00000X
MN66118207R00000X
CA174662A207SG0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine