Basic Information
| Provider Information | |||||||||
| NPI: | 1235364563 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PAING | ||||||||
| FirstName: | SOE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 45443 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841450443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042021032 | ||||||||
| FaxNumber: | 9043764107 | ||||||||
| Practice Location | |||||||||
| Address1: | 820 PRUDENTIAL DR STE 304 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322078205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043463649 | ||||||||
| FaxNumber: | 9043485627 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2009 | ||||||||
| LastUpdateDate: | 01/04/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME112113 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | P01127626 | 01 | FL | RR MEDICARE | OTHER | 005932800 | 05 | FL | MEDICAID |