Healthcare Provider Details

I. General information

NPI: 1033162060
Provider Name (Legal Business Name): CIRILO SOTELO-AVILA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 01/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 S GRAND BLVD RM G320
SAINT LOUIS MO
63104-1003
US

IV. Provider business mailing address

1465 S GRAND BLVD RM G320
SAINT LOUIS MO
63104-1003
US

V. Phone/Fax

Practice location:
  • Phone: 314-268-6424
  • Fax: 314-268-6420
Mailing address:
  • Phone: 314-268-6424
  • Fax: 314-268-6420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0213X
TaxonomyPediatric Pathology Physician
License NumberR2C91
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: