Provider Demographics
NPI:1366085763
Name:SOTO, SIMON ANDREW (IDC)
Entity type:Individual
Prefix:
First Name:SIMON
Middle Name:ANDREW
Last Name:SOTO
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 814 BOX 19
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AE
Mailing Address - Zip Code:09266-0001
Mailing Address - Country:US
Mailing Address - Phone:314-266-1583
Mailing Address - Fax:
Practice Address - Street 1:NAVAL SUPPORT ACTIVITY SOUDA BAY
Practice Address - Street 2:
Practice Address - City:CHANIA
Practice Address - State:CRETE
Practice Address - Zip Code:73100
Practice Address - Country:GR
Practice Address - Phone:282-102-1590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-18
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman