Provider Demographics
NPI:1619905783
Name:LLERENA, OTTO RAUL (MD)
Entity Type:Individual
Prefix:
First Name:OTTO
Middle Name:RAUL
Last Name:LLERENA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5500 SW 8 ST
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134
Mailing Address - Country:US
Mailing Address - Phone:305-642-5366
Mailing Address - Fax:
Practice Address - Street 1:5504 SW 8 ST.
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134
Practice Address - Country:US
Practice Address - Phone:305-441-9399
Practice Address - Fax:305-442-5409
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME62967207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL23594Medicare ID - Type Unspecified
F70265Medicare UPIN
FLF70265Medicare UPIN