Healthcare Provider Details

I. General information

NPI: 1912260258
Provider Name (Legal Business Name): ZACHARY ALLEN HOTHEM D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2012
Last Update Date: 03/23/2021
Certification Date: 03/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2780 CLEVELAND AVE STE 702
FORT MYERS FL
33901-5857
US

IV. Provider business mailing address

PO BOX 2147
FORT MYERS FL
33902-2147
US

V. Phone/Fax

Practice location:
  • Phone: 239-343-3474
  • Fax: 239-343-2968
Mailing address:
  • Phone: 239-343-3474
  • Fax: 239-343-2968

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number5101020063
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: