Healthcare Provider Details

I. General information

NPI: 1366675043
Provider Name (Legal Business Name): FREDY A OTALORA OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2009
Last Update Date: 03/23/2021
Certification Date: 03/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8051 W SUNRISE BLVD
SUNRISE FL
33322
US

IV. Provider business mailing address

PO BOX 39209
FT LAUDERDALE FL
33339
US

V. Phone/Fax

Practice location:
  • Phone: 954-474-2900
  • Fax: 954-474-2901
Mailing address:
  • Phone: 954-851-9966
  • Fax: 954-318-7360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC4484
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: