Provider Demographics
NPI:1245465269
Name:OTANO, GILBERT
Entity type:Individual
Prefix:MR
First Name:GILBERT
Middle Name:
Last Name:OTANO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3825 W 16TH AVE
Mailing Address - Street 2:STE 5
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-7005
Mailing Address - Country:US
Mailing Address - Phone:305-859-7400
Mailing Address - Fax:305-858-1100
Practice Address - Street 1:3825 W 16TH AVE
Practice Address - Street 2:STE 5
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-7005
Practice Address - Country:US
Practice Address - Phone:305-859-7400
Practice Address - Fax:305-858-1100
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-19
Last Update Date:2009-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL686834Medicare Oscar/Certification