Provider Demographics
NPI:1760430664
Name:SOARES, ROBERT L JR
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:L
Last Name:SOARES
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 SENTARA CIR STE 202
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23188-5727
Mailing Address - Country:US
Mailing Address - Phone:757-984-9850
Mailing Address - Fax:757-345-6643
Practice Address - Street 1:500 SENTARA CIR STE 202
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-5727
Practice Address - Country:US
Practice Address - Phone:757-984-9850
Practice Address - Fax:757-345-6643
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20486174400000X
VA0101263340208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC204861Medicaid
SCG51867Medicare UPIN
SC204861Medicaid