Provider Demographics
NPI:1699787556
Name:SOTO RIVAS, ISMAEL HIRAM (MD)
Entity type:Individual
Prefix:
First Name:ISMAEL
Middle Name:HIRAM
Last Name:SOTO RIVAS
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 1:2725 AIRVIEW BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-1804
Mailing Address - Country:US
Mailing Address - Phone:269-349-8386
Mailing Address - Fax:269-349-8397
Practice Address - Street 1:2725 AIRVIEW BLVD STE 105
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002
Practice Address - Country:US
Practice Address - Phone:269-349-8386
Practice Address - Fax:269-349-8397
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR13373207Q00000X
MI4301113708207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
21479 SOOtherTRIPLE-S
PR21479Medicare ID - Type Unspecified
21479 SOOtherTRIPLE-S