MEDICARE: ANDRES GERARDO SOTO BURGOS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	2000058951

General Provider Information

NPI Number	:	1053178921
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDRES GERARDO SOTO BURGOS

Provider Business Mailing Address
First Line	:	2541 FENTON AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10469-5602
Country	:	US
Telephone Number	:	347-591-8809
Fax Number	:

Provider Business Practice Location Address
First Line	:	2541 FENTON AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10469-5602
Country	:	US
Telephone Number	:	347-591-8809
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/06/2024
Last Update Date	:	02/10/2026

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