Basic Information
| Provider Information | |||||||||
| NPI: | 1841308632 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SOTO | ||||||||
| FirstName: | ALFREDO | ||||||||
| MiddleName: | JOSE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17695 OCEAN BLVD | ||||||||
| Address2: | |||||||||
| City: | ROCKAWAY BEACH | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971369689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035487363 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 182 SW ACADEMY ST | ||||||||
| Address2: | SUITE 30 | ||||||||
| City: | DALLAS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973381922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036239289 | ||||||||
| FaxNumber: | 5038311726 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 01/25/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | MD21696 | OR | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0804X | MD21696 | OR | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 2084P0800X | 4301505995 | MI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | MD21696 | 01 | OR | STATE MEDICAL LICENSE | OTHER | 2019036194 | 01 | MO | STATE MEDICAL LICENSE | OTHER | BS6902642 | 01 | DEA | OTHER | 122564 | 05 | OR | MEDICAID |