Healthcare Provider Details

I. General information

NPI: 1801823729
Provider Name (Legal Business Name): LELAND J SOTO III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 03/24/2021
Certification Date: 03/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 SEYMOUR AVE STE 101
DERBY CT
06418-1336
US

IV. Provider business mailing address

67 MAPLE AVE
DERBY CT
06418-1328
US

V. Phone/Fax

Practice location:
  • Phone: 203-732-3443
  • Fax: 855-287-1988
Mailing address:
  • Phone: 203-732-1330
  • Fax: 203-732-1332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number043520
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: