Provider Demographics
NPI:1659370146
Name:SO, JUANITO T (MD)
Entity Type:Individual
Prefix:MR
First Name:JUANITO
Middle Name:T
Last Name:SO
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:427 GUY PARK AVE - PRIMARY & SPECIALTY CARE DEPT.
Mailing Address - Street 2:ST. MARY'S HOSPITAL AT AMSTERDAM
Mailing Address - City:AMSTERDAM
Mailing Address - State:NY
Mailing Address - Zip Code:12010
Mailing Address - Country:US
Mailing Address - Phone:518-841-7430
Mailing Address - Fax:518-841-7121
Practice Address - Street 1:380 GUY PARK AVE
Practice Address - Street 2:ST. MARY'S HOSPITAL, FAM HLTH CNTR AT CARONDELET PAVILI
Practice Address - City:AMSTERDAM
Practice Address - State:NY
Practice Address - Zip Code:12010
Practice Address - Country:US
Practice Address - Phone:518-841-7415
Practice Address - Fax:518-841-7422
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2013-10-24
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Provider Licenses
StateLicense IDTaxonomies
NY137258/-1207R00000X
NY137258-1207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY10010372OtherC.D.P.H.P.
NY00462193Medicaid
NY11506OtherM.V.P.
B882291Medicare UPIN
NY70033Medicare ID - Type Unspecified