Provider Demographics
NPI:1063460590
Name:SOTO, MARIA (DO)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:SOTO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 67000
Mailing Address - Street 2:DEPT 272801
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-2728
Mailing Address - Country:US
Mailing Address - Phone:517-782-2555
Mailing Address - Fax:517-782-3399
Practice Address - Street 1:1401 W NORTH ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-3135
Practice Address - Country:US
Practice Address - Phone:517-782-2555
Practice Address - Fax:517-782-3399
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101008464207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4762331Medicaid
MIP19100001Medicare ID - Type Unspecified
MI4762331Medicaid