MEDICARE: SHARON JACOB-SOO MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	ME89945	FL
2	207N00000X	Dermatology Physician	A100287	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053349688
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHARON JACOB-SOO MD

Provider Business Mailing Address
First Line	:	3860 CALLE FORTUNADA
Second Line	:	STE #210
City	:	SAN DIEGO
State	:	CA
Zip	:	92123-4802
Country	:	US
Telephone Number	:	858-309-6303
Fax Number	:	858-309-6301

Provider Business Practice Location Address
First Line	:	3860 CALLE FORTUNADA
Second Line	:	STE #210
City	:	SAN DIEGO
State	:	CA
Zip	:	92123-4802
Country	:	US
Telephone Number	:	858-309-6303
Fax Number	:	858-309-6301

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/30/2006
Last Update Date	:	10/25/2011

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