Healthcare Provider Details

I. General information

NPI: 1669891040
Provider Name (Legal Business Name): JEAN GUY-YOMA SOUFFRANT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2014
Last Update Date: 12/21/2025
Certification Date: 12/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2795 W NEW HAVEN AVE
WEST MELBOURNE FL
32904-3705
US

IV. Provider business mailing address

95 BULLDOG BLVD STE 202
MELBOURNE FL
32901-3188
US

V. Phone/Fax

Practice location:
  • Phone: 321-372-1765
  • Fax: 888-464-0846
Mailing address:
  • Phone: 321-725-7225
  • Fax: 321-308-0635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberME149294
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberME149294
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: