Provider Demographics
NPI:1790779858
Name:SOTOLONGO, ROSE MARIE (DPM)
Entity Type:Individual
Prefix:DR
First Name:ROSE
Middle Name:MARIE
Last Name:SOTOLONGO
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:731 S PEAR ORCHARD RD
Mailing Address - Street 2:SUITE 7
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157
Mailing Address - Country:US
Mailing Address - Phone:601-206-9101
Mailing Address - Fax:601-206-9102
Practice Address - Street 1:731 S PEAR ORCHARD RD
Practice Address - Street 2:SUITE 7
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-4800
Practice Address - Country:US
Practice Address - Phone:601-206-9101
Practice Address - Fax:601-206-9102
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-06
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS80114213EP1101X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00113033Medicaid
480016317OtherRETIRED RAILROAD MEDICARE
MSU46417Medicare UPIN
MS480000054Medicare PIN