1467593780 NPI number — MYREDSI SOTO-VARELA M.D.

Table of content: MYREDSI SOTO-VARELA M.D. (NPI 1467593780)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467593780 NPI number — MYREDSI SOTO-VARELA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SOTO-VARELA
Provider First Name:
MYREDSI
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467593780
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/19/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3300 S FISKE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCKLEDGE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32955-4306
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-312-3460
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1223 GATEWAY DR STE 1A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MELBOURNE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32901-2607
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-312-3460
Provider Business Practice Location Address Fax Number:
321-768-5090
Provider Enumeration Date:
02/09/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  ME97408 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: AC925X . This is a "MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: PENDING , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 92861 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".