Provider Demographics
NPI:1659460947
Name:SODARO, DAVID L (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:L
Last Name:SODARO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:DAVID
Other - Middle Name:LEIGH
Other - Last Name:SODARO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:17360 BROOKHURST ST
Mailing Address - Street 2:ATTN: MCMF - CREDENTIALING DEPARTMENT
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-3720
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1451 IRVINE BLVD
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3804
Practice Address - Country:US
Practice Address - Phone:714-838-8878
Practice Address - Fax:714-838-8988
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2015-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA39157207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA85254Medicare UPIN
CACB224528Medicare PIN