Healthcare Provider Details

I. General information

NPI: 1619389962
Provider Name (Legal Business Name): PEDIATRIC ENT OF SOUTHWEST FLORIDA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2014
Last Update Date: 05/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 GEORGETOWN
FORT MYERS FL
33919-1088
US

IV. Provider business mailing address

19 GEORGETOWN
FORT MYERS FL
33919-1088
US

V. Phone/Fax

Practice location:
  • Phone: 210-216-5650
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License Number
License Number State

VIII. Authorized Official

Name: DOUGLAS J GOTTSCHALK
Title or Position: SOLE PROPRIETOR
Credential:
Phone: 210-216-5650