MEDICARE: MR. CYLBURN EARL SODEN SR. M.D.

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	D0024150	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	521382125	OTHER	MD	TAX ID

General Provider Information

NPI Number	:	1831168574
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CYLBURN EARL SODEN SR. M.D.

Provider Business Mailing Address
First Line	:	13920 BALTIMORE AVE
Second Line	:
City	:	LAUREL
State	:	MD
Zip	:	20707-5009
Country	:	US
Telephone Number	:	301-776-0743
Fax Number	:	301-776-0456

Provider Business Practice Location Address
First Line	:	13920 BALTIMORE AVE
Second Line	:
City	:	LAUREL
State	:	MD
Zip	:	20707-5009
Country	:	US
Telephone Number	:	301-776-0743
Fax Number	:	301-776-0456

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

Provider Enumeration Date	:	03/15/2006
Last Update Date	:	08/07/2008

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