Provider Demographics
NPI:1437761921
Name:OTERO, ISMAEL
Entity Type:Individual
Prefix:
First Name:ISMAEL
Middle Name:
Last Name:OTERO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 WESTCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:WYANDANCH
Mailing Address - State:NY
Mailing Address - Zip Code:11798-4518
Mailing Address - Country:US
Mailing Address - Phone:631-482-5635
Mailing Address - Fax:631-920-0278
Practice Address - Street 1:21 WESTCHESTER AVE
Practice Address - Street 2:
Practice Address - City:WYANDANCH
Practice Address - State:NY
Practice Address - Zip Code:11798-4518
Practice Address - Country:US
Practice Address - Phone:631-482-5635
Practice Address - Fax:631-920-0278
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-18
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYCDD9306343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)