Provider Demographics
NPI:1588812994
Name:MOCTEZUMA, SONALEE
Entity Type:Individual
Prefix:MRS
First Name:SONALEE
Middle Name:
Last Name:MOCTEZUMA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 E EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-1406
Mailing Address - Country:US
Mailing Address - Phone:813-225-7247
Mailing Address - Fax:
Practice Address - Street 1:104 E EUCLID AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33602-1406
Practice Address - Country:US
Practice Address - Phone:813-225-7247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-28
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL692515498Medicaid
FL692515496Medicaid