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General NPI Number Information
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NPI Number | 1386183218
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Entity Type | Individual
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Provider Name | MATTHEW SOBERANO D.O.
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Gender | Male
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Dates
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Enumeration Date | 02/12/2017
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Last Update Date | 11/02/2023
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Provider Practice Location Address
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Address Line | 690 DALLAS HWY STE 101
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City | VILLA RICA
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State | GA
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Zip | 30180-1262
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Country | US
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Telephone | 770-459-0620
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Fax |
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Provider Business Mailing Address
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Address Line | 10013 VINEYARD LAKE RD E
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City | JACKSONVILLE
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State | FL
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Zip | 32256-1485
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Country | US
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Telephone | 904-923-3135
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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 | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 91572
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License Number State | GA
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Taxonomy #3
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Taxonomy Code | 207K00000X
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Taxonomy Name | Allergy & Immunology Physician
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License Number | 91572
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License Number State | GA
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