=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215065362
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT E SOPER M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/01/2007
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 104 W ST
-----------------------------------------------------
City | EUREKA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95501-0834
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-445-4705
-----------------------------------------------------
Fax | 707-445-0581
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 104 W ST
-----------------------------------------------------
City | EUREKA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95501-0834
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-445-4705
-----------------------------------------------------
Fax | 707-445-0581
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | G59380
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0804X
-----------------------------------------------------
Taxonomy Name | Child & Adolescent Psychiatry Physician
-----------------------------------------------------
License Number | G59380
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------