Provider Demographics
NPI:1457640351
Name:MEJIA, OTTO RENE SR (ARNP)
Entity Type:Individual
Prefix:
First Name:OTTO
Middle Name:RENE
Last Name:MEJIA
Suffix:SR
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4105 SW 98 COURT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33165-5154
Mailing Address - Country:US
Mailing Address - Phone:305-229-5050
Mailing Address - Fax:305-229-5090
Practice Address - Street 1:4105 SW 98TH COURT
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-5154
Practice Address - Country:US
Practice Address - Phone:305-229-5090
Practice Address - Fax:305-229-5090
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-31
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 9253643363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health