MEDICARE: DR. DANNY JOSE SOARES

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	390200000X	Student in an Organized Health Care Education/Training Program
2	207YS0123X	Facial Plastic Surgery Physician	69259	GA

General Provider Information

NPI Number	:	1952568370
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DANNY JOSE SOARES

Provider Business Mailing Address
First Line	:	1402 AZALEA GARDEN DR
Second Line	:
City	:	DUNWOODY
State	:	GA
Zip	:	30338-7909
Country	:	US
Telephone Number	:	203-518-0201
Fax Number	:

Provider Business Practice Location Address
First Line	:	4553 N SHALLOWFORD RD
Second Line	:	SUITE 20B
City	:	ATLANTA
State	:	GA
Zip	:	30338-6408
Country	:	US
Telephone Number	:	770-457-6303
Fax Number	:

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

Provider Enumeration Date	:	05/22/2008
Last Update Date	:	07/25/2013

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