Healthcare Provider Details

I. General information

NPI: 1659384147
Provider Name (Legal Business Name): ODEL RUANO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 09/16/2021
Certification Date: 09/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2343 AARON ST
PORT CHARLOTTE FL
33952-5305
US

IV. Provider business mailing address

2675 WINKLER AVE FL 2
FORT MYERS FL
33901-9342
US

V. Phone/Fax

Practice location:
  • Phone: 941-629-2900
  • Fax: 941-629-6920
Mailing address:
  • Phone: 877-856-3774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME90183
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: