1255781977 NPI number — RIVERA -SOTO MEDICAL GROUP INTERNAL MEDICINE SPECIALIST

Table of content: (NPI 1255781977)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255781977 NPI number — RIVERA -SOTO MEDICAL GROUP INTERNAL MEDICINE SPECIALIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RIVERA -SOTO MEDICAL GROUP INTERNAL MEDICINE SPECIALIST
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1255781977
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/11/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
304 BLEVINS RUN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YORKTOWN
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23693-4188
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-340-8175
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
710 DENBIGH BLVD STE 7B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWPORT NEWS
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23608-4427
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-340-8175
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/14/2016

Additional Information

Authorized Official

Authorized Official Last Name:
SOTO GUERRERO
Authorized Official First Name:
YAZMIN
Authorized Official Middle Name:
JOHANNA
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
787-340-8175

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  0101260290 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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