Provider Demographics
NPI:1730265554
Name:BORSON, SOO
Entity type:Individual
Prefix:
First Name:SOO
Middle Name:
Last Name:BORSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 HOLLAND STE 101
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-2568
Mailing Address - Country:US
Mailing Address - Phone:949-588-2190
Mailing Address - Fax:
Practice Address - Street 1:490 S FARRELL DR STE C106
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-7962
Practice Address - Country:US
Practice Address - Phone:760-416-6773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG893972084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1730265554Medicaid
WA0174987OtherL&I
1970OtherINTERNAL ID-MOTOR VEHICLE ID
1970OtherINTERNAL ID-MOTOR VEHICLE ID
WA000107508Medicare PIN