Healthcare Provider Details

I. General information

NPI: 1750483210
Provider Name (Legal Business Name): OLGA BIENVENIDA SOTO-MOISE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2006
Last Update Date: 05/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 KNOLLCROFT RD LYONS VAMC BLDG 143 BP PTSD UNIT
LYONS NJ
07939-5001
US

IV. Provider business mailing address

6 WISHNOW WAY
BRIDGEWATER NJ
08807-1481
US

V. Phone/Fax

Practice location:
  • Phone: 908-647-0180
  • Fax: 908-604-5258
Mailing address:
  • Phone: 908-252-0553
  • Fax: 908-604-5258

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number25MA06606600
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number25MA06606600
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number208310
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: