Healthcare Provider Details

I. General information

NPI: 1124759741
Provider Name (Legal Business Name): KEROLLOS KEROLLOS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2022
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

636 DEL PRADO BLVD S
CAPE CORAL FL
33990-2695
US

IV. Provider business mailing address

636 DEL PRADO BLVD
CAPE CORAL FL
33990-2695
US

V. Phone/Fax

Practice location:
  • Phone: 239-424-2000
  • Fax:
Mailing address:
  • Phone: 708-202-5064
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35.155184
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number125079466
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number35.155184
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number36859
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: