MEDICARE: KIDNEY DOCTOR, CORP.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RN0300X	Nephrology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1871008508
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIDNEY DOCTOR, CORP.

Provider Business Mailing Address
First Line	:	111 N 12TH ST UNIT 1424
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33602-3674
Country	:	US
Telephone Number	:	407-718-6568
Fax Number	:

Provider Business Practice Location Address
First Line	:	4710 N HABANA AVE STE 300
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33614-7151
Country	:	US
Telephone Number	:	813-873-1016
Fax Number	:	813-874-2813

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	OTTO OSTOLAZA-GARCIA
Credential	:	MD
Telephone Number	:	813-873-1016

Provider Enumeration Date	:	12/04/2017
Last Update Date	:	12/04/2017

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Directions to “KIDNEY DOCTOR, CORP. ” Practice Location

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