Healthcare Provider Details

I. General information

NPI: 1992925051
Provider Name (Legal Business Name): WILSON NICOLAS OTERO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2007
Last Update Date: 03/28/2023
Certification Date: 03/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9149 ESTATE THOMAS PARAGON MEDICAL BUILDING SUITE 208
ST. THOMAS VI
00802-2615
US

IV. Provider business mailing address

12400 SW 1ST CT
PLANTATION FL
33325-2702
US

V. Phone/Fax

Practice location:
  • Phone: 340-714-1122
  • Fax:
Mailing address:
  • Phone: 954-483-8335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number44063
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number3572
License Number StateVI
# 3
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number44063
License Number StateAZ
# 4
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberMD00030353
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: