Provider Demographics
NPI:1801030408
Name:SOTO DE LA ROSA, EDGARDO (MD)
Entity Type:Individual
Prefix:
First Name:EDGARDO
Middle Name:
Last Name:SOTO DE LA ROSA
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 1:4235 KINGS HWY
Mailing Address - Street 2:SUITE 103
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33980-8421
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4235 KINGS HWY
Practice Address - Street 2:SUITE 103
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33980-8421
Practice Address - Country:US
Practice Address - Phone:941-613-1777
Practice Address - Fax:941-613-1779
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-27
Last Update Date:2017-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL115041207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009369200Medicaid
FL14Q6ZOtherBCBSFL
FL009369200Medicaid