Provider Demographics
NPI:1679844724
Name:SOTOMAYOR, JORGE LUIS (MA)
Entity Type:Individual
Prefix:MR
First Name:JORGE
Middle Name:LUIS
Last Name:SOTOMAYOR
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3210 W COLUMBUS DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-1816
Mailing Address - Country:US
Mailing Address - Phone:813-443-0588
Mailing Address - Fax:813-443-4722
Practice Address - Street 1:3210 W COLUMBUS DR
Practice Address - Street 2:SUITE B
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-1816
Practice Address - Country:US
Practice Address - Phone:813-443-0588
Practice Address - Fax:813-443-4722
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-21
Last Update Date:2012-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 66681225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist