Provider Demographics
NPI:1255354841
Name:PEREZ SOTO, OMAR V (MD)
Entity type:Individual
Prefix:DR
First Name:OMAR
Middle Name:V
Last Name:PEREZ SOTO
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:PO BOX 4189
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33442-4189
Mailing Address - Country:US
Mailing Address - Phone:954-363-9582
Mailing Address - Fax:954-363-9663
Practice Address - Street 1:2548 SIMPSON RD
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744
Practice Address - Country:US
Practice Address - Phone:407-632-4201
Practice Address - Fax:407-632-4206
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLACN800207QA0505X, 208D00000X
PR15643208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0022909OtherPROVIDER NUMBER
PRI28949Medicare UPIN