Provider Demographics
NPI:1689746240
Name:SOBERON, JOSE RAUL JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:RAUL
Last Name:SOBERON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 SW ARCHER RD
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32610-3003
Mailing Address - Country:US
Mailing Address - Phone:352-265-0301
Mailing Address - Fax:
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3003
Practice Address - Country:US
Practice Address - Phone:352-265-0301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME103757207L00000X
LAMD.203898207L00000X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2132113Medicaid
MS05523574Medicaid
FL017413700Medicaid
FL001492700Medicaid
FLCG286XMedicare PIN
MS05523574Medicaid
LA4P2597061Medicare PIN