Provider Demographics
NPI:1871008508
Name:KIDNEY DOCTOR, CORP.
Entity Type:Organization
Organization Name:KIDNEY DOCTOR, CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:OTTO
Authorized Official - Middle Name:
Authorized Official - Last Name:OSTOLAZA-GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-873-1016
Mailing Address - Street 1:111 N 12TH ST UNIT 1424
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-3674
Mailing Address - Country:US
Mailing Address - Phone:407-718-6568
Mailing Address - Fax:
Practice Address - Street 1:4710 N HABANA AVE STE 300
Practice Address - Street 2:
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-04
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010280100Medicaid