Provider Demographics
NPI:1942680731
Name:OTERO, JIMMY N (C-SA)
Entity Type:Individual
Prefix:
First Name:JIMMY
Middle Name:N
Last Name:OTERO
Suffix:
Gender:M
Credentials:C-SA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5079 SW 103RD AVE
Mailing Address - Street 2:
Mailing Address - City:COOPER CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33328-4900
Mailing Address - Country:US
Mailing Address - Phone:954-534-4855
Mailing Address - Fax:954-252-4073
Practice Address - Street 1:5079 SW 103RD AVE
Practice Address - Street 2:
Practice Address - City:COOPER CITY
Practice Address - State:FL
Practice Address - Zip Code:33328-4900
Practice Address - Country:US
Practice Address - Phone:954-534-4855
Practice Address - Fax:954-252-4073
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-05
Last Update Date:2015-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO15-345246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant