Provider Demographics
NPI:1992269104
Name:SOTOFALCON, SHAWN DONNIKA
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:DONNIKA
Last Name:SOTOFALCON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11921 CATO DR
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63033-6903
Mailing Address - Country:US
Mailing Address - Phone:314-346-8520
Mailing Address - Fax:
Practice Address - Street 1:11921 CATO DR
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63033-6903
Practice Address - Country:US
Practice Address - Phone:314-346-8520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-22
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0000000156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156F00000XEye and Vision Services ProvidersTechnician/TechnologistGroup - Single Specialty