Provider Demographics
NPI:1497997761
Name:SOBERON, ANGELICA MARIA (MD)
Entity Type:Individual
Prefix:
First Name:ANGELICA
Middle Name:MARIA
Last Name:SOBERON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:111 DOCTORS DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-5622
Practice Address - Country:US
Practice Address - Phone:864-797-7100
Practice Address - Fax:864-797-7105
Is Sole Proprietor?:No
Enumeration Date:2009-04-01
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC35710208100000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAPPROVEDOtherRAILROAD MEDICARE
SCAPPROVEDMedicaid
SCAPPROVEDOtherRAILROAD MEDICARE