Provider Demographics
NPI:1427128990
Name:TAHERI, KAMELA (MD)
Entity type:Individual
Prefix:DR
First Name:KAMELA
Middle Name:
Last Name:TAHERI
Suffix:
Gender:F
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:PO BOX 779
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95201-0779
Mailing Address - Country:US
Mailing Address - Phone:209-373-2800
Mailing Address - Fax:209-373-2873
Practice Address - Street 1:1721 E HAMMER LN
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95210-4124
Practice Address - Country:US
Practice Address - Phone:209-751-5200
Practice Address - Fax:209-373-2873
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC51798208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF98420Medicare ID - Type UnspecifiedPEDIATRICS