Provider Demographics
NPI:1700836566
Name:SOMOZA, EDMUNDO A (MD)
Entity Type:Individual
Prefix:
First Name:EDMUNDO
Middle Name:A
Last Name:SOMOZA
Suffix:
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:PO BOX 1046
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45802-1046
Mailing Address - Country:US
Mailing Address - Phone:419-224-5707
Mailing Address - Fax:419-229-0040
Practice Address - Street 1:11600 STATE ROUTE 424
Practice Address - Street 2:
Practice Address - City:NAPOLEON
Practice Address - State:OH
Practice Address - Zip Code:43545-9719
Practice Address - Country:US
Practice Address - Phone:419-592-4015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.0496752085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000391229OtherANTHEM BLUE CROSS BLUE SH
OH0522581Medicaid
OH0522581Medicaid
OH0623714Medicare PIN