Provider Demographics
NPI:1629189139
Name:SOTOLONGO, JORGE F (MD)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:F
Last Name:SOTOLONGO
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 1:201 RIDGE ST
Mailing Address - Street 2:#307
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-4643
Mailing Address - Country:US
Mailing Address - Phone:712-329-5700
Mailing Address - Fax:712-329-5759
Practice Address - Street 1:201 RIDGE ST
Practice Address - Street 2:#307
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-4643
Practice Address - Country:US
Practice Address - Phone:712-329-5700
Practice Address - Fax:712-329-5759
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE18305207V00000X
IA27364207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
97476OtherWELLMARK-CENTER
IA7171538Medicaid
IA8171538Medicaid
22905OtherWELLMARK-201 RIDGE
IA4171538Medicaid
97475OtherWELLMARK-S. 24TH
NE10025407200Medicaid
NE42150546518Medicaid
IA5171538Medicaid
97474OtherWELLMARK-LAKESIDE
06287OtherWELLMARK-ATLANTIC
20108OtherBCBSN
IA3171538Medicaid
NE42150546516Medicaid
NE42150546517Medicaid
NE42150546520Medicaid
IA3060582Medicaid
20108OtherBCBSN
NE273191Medicare ID - Type Unspecified
IA3171538Medicaid