Provider Demographics
NPI:1194716720
Name:SOROLLA OLYMPIA, MARICELLE G (MD)
Entity type:Individual
Prefix:
First Name:MARICELLE
Middle Name:G
Last Name:SOROLLA OLYMPIA
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 1:1650 W COLLEGE ST STE 150
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-3565
Mailing Address - Country:US
Mailing Address - Phone:817-388-3440
Mailing Address - Fax:817-388-3441
Practice Address - Street 1:1650 W COLLEGE ST STE 150
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-3565
Practice Address - Country:US
Practice Address - Phone:817-388-3440
Practice Address - Fax:817-388-3441
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN8064207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX219963001Medicaid
TXTXB119937Medicare PIN
OHI22388Medicare UPIN
TX219963001Medicaid
TX400410YKP5Medicare PIN
TX400410YKP5Medicare PIN