Basic Information
| Provider Information | |||||||||
| NPI: | 1639526338 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRIETO | ||||||||
| FirstName: | SOFIA | ||||||||
| MiddleName: | KENNEDY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KENNEDY | ||||||||
| OtherFirstName: | SOFIA | ||||||||
| OtherMiddleName: | TERESE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3601 4TH ST # MS 6211 | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794306211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103811657 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3601 4TH ST # MS 6211 | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794306211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067433150 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2016 | ||||||||
| LastUpdateDate: | 06/16/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | BP10056140 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0000X | T8021 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.