Provider Demographics
NPI:1316912082
Name:SOTOMAYOR, MARIA GAVANCHO (MD)
Entity type:Individual
Prefix:DR
First Name:MARIA
Middle Name:GAVANCHO
Last Name:SOTOMAYOR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:4919 MEMORIAL HWY STE 150
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33634-7516
Mailing Address - Country:US
Mailing Address - Phone:813-333-1512
Mailing Address - Fax:813-333-1561
Practice Address - Street 1:3622 MADACA LN
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-2057
Practice Address - Country:US
Practice Address - Phone:813-513-3643
Practice Address - Fax:813-605-5465
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME94010207N00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110175900Medicaid
DCG00383Medicare PIN