Basic Information
| Provider Information | |||||||||
| NPI: | 1184920613 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOMA MEDICAL CENTER, P. A #4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 421 S DIXIE HWY | ||||||||
| Address2: | |||||||||
| City: | LAKE WORTH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334604442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5612751155 | ||||||||
| FaxNumber: | 5612751156 | ||||||||
| Practice Location | |||||||||
| Address1: | 421 S DIXIE HWY | ||||||||
| Address2: | |||||||||
| City: | LAKE WORTH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334604442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5612751155 | ||||||||
| FaxNumber: | 5612751156 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2011 | ||||||||
| LastUpdateDate: | 12/11/2019 | ||||||||
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| AuthorizedOfficialLastName: | GADEA LOPEZ | ||||||||
| AuthorizedOfficialFirstName: | MERCEDES | ||||||||
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| AuthorizedOfficialTitleorPosition: | PEDIATRICIAN | ||||||||
| AuthorizedOfficialTelephone: | 5612751155 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOMA MEDICAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 12/11/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | ME102127 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 005584600 | 05 | FL | MEDICAID |