Provider Demographics
NPI:1629158217
Name:SORIANO, TERESA TABORA (MD)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:TABORA
Last Name:SORIANO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:TABORA
Other - Last Name:SORIANO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:200 MEDICAL PLAZA
Mailing Address - Street 2:465
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095
Mailing Address - Country:US
Mailing Address - Phone:310-825-6911
Mailing Address - Fax:310-794-7005
Practice Address - Street 1:200 MEDICAL PLAZA
Practice Address - Street 2:#450
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095
Practice Address - Country:US
Practice Address - Phone:310-825-6911
Practice Address - Fax:310-794-7005
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA62639207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G629740Medicaid
CAGQ699ZMedicare PIN
CAG62974Medicare UPIN
CAWA62639BMedicare PIN