Provider Demographics
NPI:1699703264
Name:KAUKAB, SHAHLA AMJAD (MD)
Entity type:Individual
Prefix:DR
First Name:SHAHLA
Middle Name:AMJAD
Last Name:KAUKAB
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 1059
Mailing Address - Street 2:
Mailing Address - City:SODDY DAISY
Mailing Address - State:TN
Mailing Address - Zip Code:37384
Mailing Address - Country:US
Mailing Address - Phone:423-451-0623
Mailing Address - Fax:423-451-0624
Practice Address - Street 1:9089 DAYTON PIKE
Practice Address - Street 2:
Practice Address - City:SODDY DAISY
Practice Address - State:TN
Practice Address - Zip Code:37379
Practice Address - Country:US
Practice Address - Phone:423-451-0623
Practice Address - Fax:423-451-0624
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN37633208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3887638Medicaid