Basic Information
| Provider Information | |||||||||
| NPI: | 1467463497 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SOBLE | ||||||||
| FirstName: | SHELDON | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2193 NORTHLAKE PARKWAY | ||||||||
| Address2: | BUILDING 12 SUITE 114 | ||||||||
| City: | TUCKER | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709382920 | ||||||||
| FaxNumber: | 7709397393 | ||||||||
| Practice Location | |||||||||
| Address1: | 2193 NORTHLAKE PARKWAY | ||||||||
| Address2: | BUILDING 12 SUITE 114 | ||||||||
| City: | TUCKER | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709382920 | ||||||||
| FaxNumber: | 7709397393 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 04/23/2008 | ||||||||
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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 | 213E00000X | 331 | GA | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 00006135A | 05 | GA | MEDICAID | 2700159 | 01 | GA | EVERCARE | OTHER | 480403327 | 01 | RR MEDICARE | OTHER | 52134986 | 01 | GA | BLUE CROSS | OTHER |