Basic Information
| Provider Information | |||||||||
| NPI: | 1699854117 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SOOD | ||||||||
| FirstName: | MRIDULA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 140 ACADEMY ST | ||||||||
| Address2: | |||||||||
| City: | PRESQUE ISLE | ||||||||
| State: | ME | ||||||||
| PostalCode: | 047693102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077643142 | ||||||||
| FaxNumber: | 2077608170 | ||||||||
| Practice Location | |||||||||
| Address1: | 140 ACADEMY ST | ||||||||
| Address2: | |||||||||
| City: | PRESQUE ISLE | ||||||||
| State: | ME | ||||||||
| PostalCode: | 047693102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077643142 | ||||||||
| FaxNumber: | 2077608170 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2006 | ||||||||
| LastUpdateDate: | 10/19/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD19354 | ME | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1699854117 | 05 | ME | MEDICAID |