MEDICARE: SOMA MEDICAL CENTER, P. A #4

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	208000000X	Pediatrics Physician	ME102127	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1184920613
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOMA MEDICAL CENTER, P. A #4

Provider Business Mailing Address
First Line	:	421 S DIXIE HWY
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33460-4442
Country	:	US
Telephone Number	:	561-275-1155
Fax Number	:	561-275-1156

Provider Business Practice Location Address
First Line	:	421 S DIXIE HWY
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33460-4442
Country	:	US
Telephone Number	:	561-275-1155
Fax Number	:	561-275-1156

Authorized Official
Title or Position	:	PEDIATRICIAN
Name	:	DR. MERCEDES GADEA LOPEZ
Credential	:	MD
Telephone Number	:	561-275-1155

Provider Enumeration Date	:	02/01/2011
Last Update Date	:	12/11/2019

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