Healthcare Provider Details

I. General information

NPI: 1275960379
Provider Name (Legal Business Name): DR. JOHANNIS SOTO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2013
Last Update Date: 10/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8011 CALLE CONCORDIA APT. 2
PONCE PR
00717
US

IV. Provider business mailing address

PO BOX 336810
PONCE PR
00733-6810
US

V. Phone/Fax

Practice location:
  • Phone: 787-219-2604
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number29572R
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: