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General NPI Number Information
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NPI Number | 1083938575
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Entity Type | Individual
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Provider Name | JANE SO M.D.
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Gender | Female
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Dates
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Enumeration Date | 03/26/2010
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Last Update Date | 11/13/2023
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Provider Practice Location Address
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Address Line | 1 HEROES WAY
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City | RIVERHEAD
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State | NY
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Zip | 11901-2058
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Country | US
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Telephone | 631-548-6113
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Fax |
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Provider Business Mailing Address
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Address Line | 69A GNARLED HOLLOW RD
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City | EAST SETAUKET
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State | NY
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Zip | 11733-2026
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Country | US
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Telephone | 201-417-9649
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number | FS4460274
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License Number State | NY
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