Provider Demographics
NPI:1619389962
Name:PEDIATRIC ENT OF SOUTHWEST FLORIDA PLLC
Entity Type:Organization
Organization Name:PEDIATRIC ENT OF SOUTHWEST FLORIDA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:GOTTSCHALK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-216-5650
Mailing Address - Street 1:19 GEORGETOWN
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-1088
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19 GEORGETOWN
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-1088
Practice Address - Country:US
Practice Address - Phone:210-216-5650
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-21
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YP0228XAllopathic & Osteopathic PhysiciansOtolaryngologyPediatric OtolaryngologyGroup - Single Specialty