Healthcare Provider Details

I. General information

NPI: 1124947049
Provider Name (Legal Business Name): RUSSELL SOFFER OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2026
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1770 NW 122ND TER
PEMBROKE PINES FL
33026-1967
US

IV. Provider business mailing address

18991 SW 41ST ST
MIRAMAR FL
33029-2759
US

V. Phone/Fax

Practice location:
  • Phone: 954-433-1490
  • Fax:
Mailing address:
  • Phone: 954-348-4933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC7031
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: