Provider Demographics
NPI:1821269051
Name:OSTOLAZA-GARCIA, OTTO (MD)
Entity Type:Individual
Prefix:
First Name:OTTO
Middle Name:
Last Name:OSTOLAZA-GARCIA
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 1:4710 N HABANA AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-7151
Mailing Address - Country:US
Mailing Address - Phone:813-873-1016
Mailing Address - Fax:813-874-2813
Practice Address - Street 1:4710 N HABANA AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-7151
Practice Address - Country:US
Practice Address - Phone:813-873-1016
Practice Address - Fax:813-874-2813
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-15
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR17275207R00000X
FLME117767207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010280100Medicaid
FLME117767OtherLICENSE NO
FLP01402860OtherRR MEDICARE
FL010280100Medicaid