Provider Demographics
NPI:1821141680
Name:OTERO-RODRIGUEZ, NELLY A (MD)
Entity Type:Individual
Prefix:
First Name:NELLY
Middle Name:A
Last Name:OTERO-RODRIGUEZ
Suffix:
Gender:F
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:PO BOX 2379
Mailing Address - Street 2:MINNEOLA
Mailing Address - City:MINNEOLA
Mailing Address - State:FL
Mailing Address - Zip Code:34755-2379
Mailing Address - Country:US
Mailing Address - Phone:352-255-3229
Mailing Address - Fax:180-059-2900
Practice Address - Street 1:2445 LANE PARK RD
Practice Address - Street 2:TAVARES
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-9648
Practice Address - Country:US
Practice Address - Phone:352-742-6813
Practice Address - Fax:352-343-0325
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME52940207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL09918OtherBCBS
FLF75285Medicare UPIN
FL09918OtherBCBS