Provider Demographics
NPI:1912965245
Name:SOMOHANO, JOSE V (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:V
Last Name:SOMOHANO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JOSE
Other - Middle Name:VICENTE
Other - Last Name:SOMOHANO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:20 GLENLAKE PKWY
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328
Mailing Address - Country:US
Mailing Address - Phone:770-677-6037
Mailing Address - Fax:770-677-7324
Practice Address - Street 1:20 GLENLAKE PKWY
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328
Practice Address - Country:US
Practice Address - Phone:770-677-6037
Practice Address - Fax:770-677-7324
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA022645208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
C83851Medicare UPIN