Provider Demographics
NPI:1184613077
Name:SOTILLO, MELISSA MARIA (MD)
Entity type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:MARIA
Last Name:SOTILLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 WOODPORT RD
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:NJ
Mailing Address - Zip Code:07871-2339
Mailing Address - Country:US
Mailing Address - Phone:973-726-0801
Mailing Address - Fax:973-726-0802
Practice Address - Street 1:147 WOODPORT RD
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:NJ
Practice Address - Zip Code:07871-2339
Practice Address - Country:US
Practice Address - Phone:973-726-0801
Practice Address - Fax:973-726-0802
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-14
Last Update Date:2012-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA07760500174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0051144Medicaid
NJI20097Medicare UPIN
NJ0051144Medicaid