Provider Demographics
NPI:1386056430
Name:SOUFFRANT, EDMIRE FLORE (MD)
Entity type:Individual
Prefix:
First Name:EDMIRE
Middle Name:FLORE
Last Name:SOUFFRANT
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:501 BILLINGSLEY RD
Practice Address - Street 2:STE B
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1009
Practice Address - Country:US
Practice Address - Phone:704-444-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-23
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2015-02319207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC201283OtherRESIDENT TRAINING LICENSE
NCAC5385578-R126OtherDEA