MEDICARE: DR. LUIS ALBERTO SORO JR. D.O.

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	207N00000X	Dermatology Physician	OT013899	PA
2	207NS0135X	Procedural Dermatology Physician	OS12533	FL

General Provider Information

NPI Number	:	1649585639
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LUIS ALBERTO SORO JR. D.O.

Provider Business Mailing Address
First Line	:	2009 SE 10TH AVE
Second Line	:	APT #322
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33316-4503
Country	:	US
Telephone Number	:	305-975-3130
Fax Number	:

Provider Business Practice Location Address
First Line	:	350 E LAS OLAS BLVD
Second Line	:	SUITE 110
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33301-4211
Country	:	US
Telephone Number	:	954-765-3005
Fax Number	:

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

Provider Enumeration Date	:	08/13/2010
Last Update Date	:	07/30/2014

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