Provider Demographics
NPI:1811041247
Name:NAM, SOO Y (MD)
Entity Type:Individual
Prefix:DR
First Name:SOO
Middle Name:Y
Last Name:NAM
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 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:701 W COCOA BEACH CSWY
Practice Address - Street 2:
Practice Address - City:COCOA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32931
Practice Address - Country:US
Practice Address - Phone:321-868-5871
Practice Address - Fax:321-868-5852
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME101539207R00000X, 208M00000X
GA064422207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAK637TOtherMEDICARE HF
FL281280100Medicaid
GAP01161202OtherRAILROAD MEDICARE
GA01779541OtherAMERIGROUP
GAN752086OtherWELLCARE
GA003130579AMedicaid
GA202I113496Medicare PIN
FLAK637ZMedicare PIN