Provider Demographics
NPI:1376058263
Name:OTANO, SONMAY
Entity Type:Individual
Prefix:
First Name:SONMAY
Middle Name:
Last Name:OTANO
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 1:13233 SW 200TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33177-6150
Mailing Address - Country:US
Mailing Address - Phone:786-445-8964
Mailing Address - Fax:
Practice Address - Street 1:13233 SW 200TH TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33177-6150
Practice Address - Country:US
Practice Address - Phone:786-445-8964
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-13
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11-1210-GH261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities