Provider Demographics
NPI:1952486987
Name:REMEDIOS, OTHOLINO (MD)
Entity Type:Individual
Prefix:
First Name:OTHOLINO
Middle Name:
Last Name:REMEDIOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:OTTO
Other - Middle Name:
Other - Last Name:REMEDIOS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1111 MEDICAL CENTER BLVD
Mailing Address - Street 2:SUITE N-502
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-3151
Mailing Address - Country:US
Mailing Address - Phone:504-347-0202
Mailing Address - Fax:504-341-6475
Practice Address - Street 1:1200 AVENUE G
Practice Address - Street 2:SUITE # 101,
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-3765
Practice Address - Country:US
Practice Address - Phone:504-347-0202
Practice Address - Fax:504-341-6475
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5066R2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1957798Medicaid