Provider Demographics
NPI:1366675043
Name:OTALORA, FREDY A (OD)
Entity Type:Individual
Prefix:
First Name:FREDY
Middle Name:A
Last Name:OTALORA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 39209
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33339
Mailing Address - Country:US
Mailing Address - Phone:954-851-9966
Mailing Address - Fax:954-318-7360
Practice Address - Street 1:8051 W SUNRISE BLVD
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33322
Practice Address - Country:US
Practice Address - Phone:954-474-2900
Practice Address - Fax:954-474-2901
Is Sole Proprietor?:No
Enumeration Date:2009-08-28
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC4484152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCL029ZMedicare PIN