Provider Demographics
NPI:1891350187
Name:SOTOS, MARYELAINE (DO)
Entity Type:Individual
Prefix:
First Name:MARYELAINE
Middle Name:
Last Name:SOTOS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3410 FAR WEST BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-3187
Mailing Address - Country:US
Mailing Address - Phone:512-717-9775
Mailing Address - Fax:
Practice Address - Street 1:3410 FAR WEST BLVD STE 100
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-3187
Practice Address - Country:US
Practice Address - Phone:512-717-9775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-02
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10066943207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine