Provider Demographics
NPI:1124113782
Name:SOMODEVILLA, GUILLERMO (MD)
Entity type:Individual
Prefix:DR
First Name:GUILLERMO
Middle Name:
Last Name:SOMODEVILLA
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 1:7805 CORAL WAY STE 126
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-6553
Mailing Address - Country:US
Mailing Address - Phone:305-269-0385
Mailing Address - Fax:305-269-0386
Practice Address - Street 1:7805 CORAL WAY STE 126
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-6553
Practice Address - Country:US
Practice Address - Phone:305-269-0385
Practice Address - Fax:305-269-0386
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0049294207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL045609800Medicaid
FL045609800Medicaid
FL03725Medicare ID - Type Unspecified