Provider Demographics
NPI:1093710097
Name:SOVRAN, PAUL DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:DAVID
Last Name:SOVRAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 EAST RUBY AVE
Mailing Address - Street 2:
Mailing Address - City:KISSIMME
Mailing Address - State:FL
Mailing Address - Zip Code:34741-5679
Mailing Address - Country:US
Mailing Address - Phone:407-847-3333
Mailing Address - Fax:407-847-8622
Practice Address - Street 1:211 EAST RUBY AVE
Practice Address - Street 2:
Practice Address - City:KISSIMME
Practice Address - State:FL
Practice Address - Zip Code:34741-5679
Practice Address - Country:US
Practice Address - Phone:407-847-3333
Practice Address - Fax:407-847-8622
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2011-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME039107207R00000X, 207RG0300X, 2083A0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL47471OtherBCBS
FLD55072Medicare UPIN
FL47471OtherBCBS