Provider Demographics
NPI:1790215002
Name:SOZA, AMANDA VICTORIA (MD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:VICTORIA
Last Name:SOZA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6210 E HIGHWAY 290 STE 420
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78723-1142
Mailing Address - Country:US
Mailing Address - Phone:512-483-9569
Mailing Address - Fax:512-406-6216
Practice Address - Street 1:22420 IH 35 STE 203
Practice Address - Street 2:
Practice Address - City:KYLE
Practice Address - State:TX
Practice Address - Zip Code:78640-2656
Practice Address - Country:US
Practice Address - Phone:407-649-6876
Practice Address - Fax:407-872-0544
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-19
Last Update Date:2021-03-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXS7146208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX419459904Medicaid
TX419459903Medicaid