Provider Demographics
NPI:1659540565
Name:CELESTE S SOBERANO MD PA
Entity Type:Organization
Organization Name:CELESTE S SOBERANO MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:CELESTE
Authorized Official - Middle Name:S
Authorized Official - Last Name:SOBERANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD PA
Authorized Official - Phone:904-996-8090
Mailing Address - Street 1:8833 PERIMETER PARK BLVD
Mailing Address - Street 2:SUITE 401
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-1109
Mailing Address - Country:US
Mailing Address - Phone:904-996-8090
Mailing Address - Fax:
Practice Address - Street 1:8833 PERIMETER PARK BLVD
Practice Address - Street 2:SUITE 401
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-1109
Practice Address - Country:US
Practice Address - Phone:904-996-8090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-25
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME78567207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1659540565Medicare NSC
FLK1997Medicare PIN
FLF81850Medicare UPIN