MEDICARE: SOTA MEDICAL SERVICES PC

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	174400000X	Specialist	205859	NY

General Provider Information

NPI Number	:	1477654523
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOTA MEDICAL SERVICES PC

Provider Business Mailing Address
First Line	:	1416 BEVERLEY RD
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11226-4514
Country	:	US
Telephone Number	:	718-469-3377
Fax Number	:

Provider Business Practice Location Address
First Line	:	1416 BEVERLEY RD
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11226-4514
Country	:	US
Telephone Number	:	718-469-3377
Fax Number	:

Authorized Official
Title or Position	:	SOLE PROPRIETER
Name	:	THERESE MALCOLM
Credential	:
Telephone Number	:	917-548-7265

Provider Enumeration Date	:	09/25/2006
Last Update Date	:	08/22/2020

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