Basic Information
| Provider Information | |||||||||
| NPI: | 1669891040 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SOUFFRANT | ||||||||
| FirstName: | JEAN | ||||||||
| MiddleName: | GUY-YOMA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 95 BULLDOG BLVD STE 202 | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329013188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217257225 | ||||||||
| FaxNumber: | 3213080635 | ||||||||
| Practice Location | |||||||||
| Address1: | 1344 S APOLLO BLVD STE 300 | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329013185 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217252225 | ||||||||
| FaxNumber: | 3213080635 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2014 | ||||||||
| LastUpdateDate: | 10/18/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | ME149294 | FL | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | PY774 | 01 | FL | HF MA | OTHER |