=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790972495
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIA MAGNOLIA SORIANO ESPEJO MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2007
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1303 STATE ST
-----------------------------------------------------
City | MOUND CITY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64470-1717
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 660-442-5464
-----------------------------------------------------
Fax | 660-442-5927
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1303 STATE ST
-----------------------------------------------------
City | MOUND CITY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64470-1717
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 660-442-5464
-----------------------------------------------------
Fax | 660-442-5927
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 2008035883
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------