Basic Information
| Provider Information | |||||||||
| NPI: | 1164407201 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SOTO | ||||||||
| FirstName: | DALISLA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 12493 | ||||||||
| Address2: | JMG SPECIALTY PHYSICIANS | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331012493 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055856649 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1801 NW 9TH AVE | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331361005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7864668490 | ||||||||
| FaxNumber: | 3055736562 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2005 | ||||||||
| LastUpdateDate: | 01/06/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME059438 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 54444200 | 05 | FL | MEDICAID |