Provider Demographics
NPI:1053349688
Name:JACOB-SOO, SHARON (MD)
Entity type:Individual
Prefix:
First Name:SHARON
Middle Name:
Last Name:JACOB-SOO
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 1:3860 CALLE FORTUNADA
Mailing Address - Street 2:STE #210
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4802
Mailing Address - Country:US
Mailing Address - Phone:858-309-6303
Mailing Address - Fax:858-309-6301
Practice Address - Street 1:3860 CALLE FORTUNADA
Practice Address - Street 2:STE #210
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4802
Practice Address - Country:US
Practice Address - Phone:858-309-6303
Practice Address - Fax:858-309-6301
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME89945207N00000X
CAA100287207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2704986-00Medicaid
FL48570Medicare ID - Type Unspecified
FL2704986-00Medicaid