MEDICARE: MICHAEL GABRIEL DE JESUS SOTO

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	390200000X	Student in an Organized Health Care Education/Training Program		PR

General Provider Information

NPI Number	:	1467380055
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL GABRIEL DE JESUS SOTO

Provider Business Mailing Address
First Line	:	M87 CALLE SANTIAGO
Second Line	:
City	:	BAYAMON
State	:	PR
Zip	:	00956-2815
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	M87 CALLE SANTIAGO
Second Line	:
City	:	BAYAMON
State	:	PR
Zip	:	00956-2815
Country	:	US
Telephone Number	:	939-260-0434
Fax Number	:

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

Provider Enumeration Date	:	05/12/2026
Last Update Date	:	05/12/2026

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