Provider Demographics
NPI:1285625467
Name:SOBERANO, CELESTE S (MD)
Entity type:Individual
Prefix:
First Name:CELESTE
Middle Name:S
Last Name:SOBERANO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8833 PERIMETER PARK BLVD
Mailing Address - Street 2:SUITE 401
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-1109
Mailing Address - Country:US
Mailing Address - Phone:904-996-8090
Mailing Address - Fax:904-996-0790
Practice Address - Street 1:8833 PERIMETER PARK BLVD
Practice Address - Street 2:SUITE 401
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-1109
Practice Address - Country:US
Practice Address - Phone:904-996-8090
Practice Address - Fax:904-996-0790
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-04
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME78567207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL46983YMedicare PIN
FLF81850Medicare UPIN