Basic Information
| Provider Information | |||||||||
| NPI: | 1447387477 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SODA | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | M | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1414 E MAIN ST STE 201 | ||||||||
| Address2: | |||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934544890 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 235 S PALISADE DR | ||||||||
| Address2: | |||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8057393561 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2007 | ||||||||
| LastUpdateDate: | 07/11/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | A72328 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 39948 | CO | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 76434354 | 05 | CO | MEDICAID |