Basic Information
Provider Information
NPI: 1811381908
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: SORATHIA
FirstName: SAFIYYAH
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: B.A.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 2711 CRANES COVE DR
Address2:  
City: KISSIMMEE
State: FL
PostalCode: 347417504
CountryCode: US
TelephoneNumber: 8133777393
FaxNumber:  
Practice Location
Address1: 1000 W BROADWAY ST STE 214
Address2:  
City: OVIEDO
State: FL
PostalCode: 327659262
CountryCode: US
TelephoneNumber: 4073595693
FaxNumber:  
Other Information
ProviderEnumerationDate: 03/26/2015
LastUpdateDate: 12/03/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
106S00000X  Y    

ID Information
IDTypeStateIssuerDescription
01986180005FL MEDICAID


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