Provider Demographics
NPI:1184920613
Name:SOMA MEDICAL CENTER, P. A #4
Entity type:Organization
Organization Name:SOMA MEDICAL CENTER, P. A #4
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MERCEDES
Authorized Official - Middle Name:
Authorized Official - Last Name:GADEA LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-275-1155
Mailing Address - Street 1:421 S DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33460-4442
Mailing Address - Country:US
Mailing Address - Phone:561-275-1155
Mailing Address - Fax:561-275-1156
Practice Address - Street 1:421 S DIXIE HWY
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33460-4442
Practice Address - Country:US
Practice Address - Phone:561-275-1155
Practice Address - Fax:561-275-1156
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOMA MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-02-01
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME102127208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL005584600Medicaid