Provider Demographics
NPI:1245204270
Name:SOE, LYNDON (DO)
Entity Type:Individual
Prefix:
First Name:LYNDON
Middle Name:
Last Name:SOE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4901 34TH ST S
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33711-4511
Mailing Address - Country:US
Mailing Address - Phone:727-866-9945
Mailing Address - Fax:727-866-9870
Practice Address - Street 1:4901 34TH ST S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33711-4511
Practice Address - Country:US
Practice Address - Phone:727-866-9945
Practice Address - Fax:727-866-9870
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7709207Q00000X
FLOS07709207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL260060900Medicaid
FL260060900Medicaid
FLE6045ZMedicare PIN