Healthcare Provider Details

I. General information

NPI: 1134425242
Provider Name (Legal Business Name): LAZARO ROQUE COTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2011
Last Update Date: 02/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1897 NE 146TH ST
NORTH MIAMI FL
33181-1423
US

IV. Provider business mailing address

1897 NE 146TH ST
NORTH MIAMI FL
33181-1423
US

V. Phone/Fax

Practice location:
  • Phone: 305-949-4191
  • Fax: 305-949-4833
Mailing address:
  • Phone: 305-949-4191
  • Fax: 305-949-4833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberOAT 11601
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: