Healthcare Provider Details

I. General information

NPI: 1457640351
Provider Name (Legal Business Name): OTTO RENE MEJIA SR. ARNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2011
Last Update Date: 03/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4105 SW 98TH COURT
MIAMI FL
33165-5154
US

IV. Provider business mailing address

4105 SW 98 COURT
MIAMI FL
33165-5154
US

V. Phone/Fax

Practice location:
  • Phone: 305-229-5090
  • Fax: 305-229-5090
Mailing address:
  • Phone: 305-229-5050
  • Fax: 305-229-5090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberARNP 9253643
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: