Provider Demographics
NPI:1821439274
Name:SOEDERBAUM, NADEEN LUCERO (MD)
Entity Type:Individual
Prefix:
First Name:NADEEN
Middle Name:LUCERO
Last Name:SOEDERBAUM
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 1:221 REGENCY PKWY
Mailing Address - Street 2:STE 125
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-5379
Mailing Address - Country:US
Mailing Address - Phone:817-477-5884
Mailing Address - Fax:855-620-7823
Practice Address - Street 1:221 REGENCY PKWY
Practice Address - Street 2:STE 125
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-5379
Practice Address - Country:US
Practice Address - Phone:817-477-5884
Practice Address - Fax:855-620-7823
Is Sole Proprietor?:No
Enumeration Date:2013-07-15
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS892-L207R00000X
TXQ8627207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX362955201Medicaid
TX362955202Medicaid
TX362955202Medicaid
TX530484ZRVTMedicare PIN