Provider Demographics
NPI:1386633394
Name:SOE, KATHLEEN P (DO)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:P
Last Name:SOE
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 1:4651 VAN DYKE RD
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33558-4880
Mailing Address - Country:US
Mailing Address - Phone:813-321-1786
Mailing Address - Fax:813-321-1787
Practice Address - Street 1:725 VIRGINIA STREET
Practice Address - Street 2:
Practice Address - City:DUNEDIN
Practice Address - State:FL
Practice Address - Zip Code:34698-6615
Practice Address - Country:US
Practice Address - Phone:727-734-4551
Practice Address - Fax:727-736-8648
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-21
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS8204174400000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL7881565OtherAETNA PPO
FL293930OtherAVMED
FL3491438OtherAETNA HMO
FL6272360OtherCIGNA
FL3491438OtherAETNA HMO
FLY10486Medicare UPIN