Provider Demographics
NPI:1760655757
Name:SOTO, CAULLEY FONVIELLE (MD)
Entity Type:Individual
Prefix:
First Name:CAULLEY
Middle Name:FONVIELLE
Last Name:SOTO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 S GADSDEN ST
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32301-5506
Mailing Address - Country:US
Mailing Address - Phone:850-576-4073
Mailing Address - Fax:850-576-2824
Practice Address - Street 1:1720 S GADSDEN ST
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32301-5506
Practice Address - Country:US
Practice Address - Phone:850-576-4073
Practice Address - Fax:850-576-2824
Is Sole Proprietor?:No
Enumeration Date:2008-04-10
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME96885208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSG097141OtherVISTA
FL281225800Medicaid