Provider Demographics
NPI:1811263122
Name:SOTO-FOURNIER, MANUEL (MD)
Entity type:Individual
Prefix:
First Name:MANUEL
Middle Name:
Last Name:SOTO-FOURNIER
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 1:7253 AMBASSADOR RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21244-2710
Mailing Address - Country:US
Mailing Address - Phone:443-436-1221
Mailing Address - Fax:443-436-1256
Practice Address - Street 1:7253 AMBASSADOR RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21244
Practice Address - Country:US
Practice Address - Phone:443-436-1221
Practice Address - Fax:443-436-1256
Is Sole Proprietor?:No
Enumeration Date:2012-03-30
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD830302085B0100X
390200000X
MDD00830302085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD211243400Medicaid