Healthcare Provider Details

I. General information

NPI: 1740634518
Provider Name (Legal Business Name): SOUMYA JUDSON BEN M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SOUMYA S.P M.D

II. Dates (important events)

Enumeration Date: 04/19/2016
Last Update Date: 10/02/2025
Certification Date: 10/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14254 DR MARTIN LUTHER KING JR BLVD
DOVER FL
33527-4414
US

IV. Provider business mailing address

14254 DR MARTIN LUTHER KING JR BLVD
DOVER FL
33527-4414
US

V. Phone/Fax

Practice location:
  • Phone: 813-653-6100
  • Fax:
Mailing address:
  • Phone: 813-653-6100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME142125
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: