Provider Demographics
NPI:1639282791
Name:SOHA, MARY E (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:E
Last Name:SOHA
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 1:4051 ATLANTIC BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-2036
Mailing Address - Country:US
Mailing Address - Phone:904-393-4700
Mailing Address - Fax:904-493-9700
Practice Address - Street 1:4051 ATLANTIC BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-2036
Practice Address - Country:US
Practice Address - Phone:904-393-4700
Practice Address - Fax:904-493-9700
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0056953174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE84052Medicare UPIN