Healthcare Provider Details

I. General information

NPI: 1366085763
Provider Name (Legal Business Name): SIMON ANDREW SOTO IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2019
Last Update Date: 11/18/2024
Certification Date: 11/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NAVAL SUPPORT ACTIVITY SOUDA BAY
CHANIA CRETE
73100
GR

IV. Provider business mailing address

PSC 814 BOX 19
FPO AE
09266-0001
US

V. Phone/Fax

Practice location:
  • Phone: 282-102-1590
  • Fax:
Mailing address:
  • Phone: 314-266-1583
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: