Provider Demographics
NPI:1013192574
Name:SOTO, WILMER I (MA)
Entity Type:Individual
Prefix:
First Name:WILMER
Middle Name:I
Last Name:SOTO
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DT28 CALLE LAGO ICACO
Mailing Address - Street 2:5TALEVITTOWN
Mailing Address - City:TOA BAJA
Mailing Address - State:PR
Mailing Address - Zip Code:00949-3529
Mailing Address - Country:US
Mailing Address - Phone:787-633-2704
Mailing Address - Fax:
Practice Address - Street 1:DT28 CALLE LAGO ICACO
Practice Address - Street 2:5TALEVITTOWN
Practice Address - City:TOA BAJA
Practice Address - State:PR
Practice Address - Zip Code:00949-3529
Practice Address - Country:US
Practice Address - Phone:787-633-2704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-03
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR301261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder