Basic Information
| Provider Information | |||||||||
| NPI: | 1992746283 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | SOUD | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | GLEN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 40767 | ||||||||
| Address2: | CREDENTIALING DEPARTMENT | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322030767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043763707 | ||||||||
| FaxNumber: | 9043915807 | ||||||||
| Practice Location | |||||||||
| Address1: | 14810 OLD SAINT AUGUSTINE RD STE 106 | ||||||||
| Address2: | CREDENTIALING DEPARTMENT | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322582558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042687701 | ||||||||
| FaxNumber: | 9042689708 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 02/03/2015 | ||||||||
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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 | 208000000X | ME29971 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 059637701 | 05 | FL | MEDICAID |