=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083469399
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOPI MEDICAL PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2024
-----------------------------------------------------
Last Update Date | 05/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 53 FOX DEN RD
-----------------------------------------------------
City | MOUNT KISCO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10549-3834
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-724-1819
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 53 FOX DEN RD
-----------------------------------------------------
City | MOUNT KISCO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10549-3834
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-724-1819
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | INDIRA GJONI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 816-724-1819
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------