Healthcare Provider Details

I. General information

NPI: 1962787937
Provider Name (Legal Business Name): DAVID THOMAS HOTWAGNER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2011
Last Update Date: 10/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 SE TIFFANY AVE
PORT ST LUCIE FL
34952-7521
US

IV. Provider business mailing address

1800 SE TIFFANY AVE
PORT ST LUCIE FL
34952-7521
US

V. Phone/Fax

Practice location:
  • Phone: 772-335-4000
  • Fax:
Mailing address:
  • Phone: 772-335-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberU02784
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: