Healthcare Provider Details

I. General information

NPI: 1720021009
Provider Name (Legal Business Name): DOMENIC VINCENT OTTAIANO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 10/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 AVENUE F NE
WINTER HAVEN FL
33881-4131
US

IV. Provider business mailing address

PO BOX 864165
ORLANDO FL
32886-4215
US

V. Phone/Fax

Practice location:
  • Phone: 862-293-1121
  • Fax:
Mailing address:
  • Phone: 317-614-9863
  • Fax: 844-876-0873

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberME0057744
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: