Provider Demographics
NPI:1295059061
Name:SOTELO, ROMAN ALLAN SAMSON (RPT)
Entity type:Individual
Prefix:
First Name:ROMAN ALLAN
Middle Name:SAMSON
Last Name:SOTELO
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3023 23RD ST
Mailing Address - Street 2:APARTMENT 3
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11102-3327
Mailing Address - Country:US
Mailing Address - Phone:909-992-2152
Mailing Address - Fax:134-762-1452
Practice Address - Street 1:1070 HAVEMEYER AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462-5310
Practice Address - Country:US
Practice Address - Phone:718-863-6200
Practice Address - Fax:914-530-2161
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-22
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028622225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist