=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508418153
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | FRANCISCO TELLECHEA ROTTA MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2019
-----------------------------------------------------
Last Update Date | 10/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11715 RANGELAND PKWY
-----------------------------------------------------
City | BRADENTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34211-9529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-538-0088
-----------------------------------------------------
Fax | 941-538-0089
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11715 RANGELAND PKWY
-----------------------------------------------------
City | BRADENTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34211-9529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-538-0087
-----------------------------------------------------
Fax | 941-538-0089
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 204R00000X
-----------------------------------------------------
Taxonomy Name | Electrodiagnostic Medicine Physician
-----------------------------------------------------
License Number | ME139605
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | ME139605
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------