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General NPI Number Information
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NPI Number | 1871008508
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Entity Type | Organization
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Legal Business Name | KIDNEY DOCTOR, CORP.
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Dates
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Enumeration Date | 12/04/2017
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Last Update Date | 12/04/2017
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Provider Practice Location Address
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Address Line | 4710 N HABANA AVE STE 300
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City | TAMPA
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State | FL
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Zip | 33614-7151
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Country | US
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Telephone | 813-873-1016
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Fax | 813-874-2813
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Provider Business Mailing Address
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Address Line | 111 N 12TH ST UNIT 1424
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City | TAMPA
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State | FL
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Zip | 33602-3674
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Country | US
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Telephone | 407-718-6568
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Fax |
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Authorized Official
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Title or Position | OWNER/PRESIDENT
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Name | OTTO OSTOLAZA-GARCIA
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Credential | MD
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Telephone | 813-873-1016
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RN0300X
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Taxonomy Name | Nephrology Physician
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License Number |
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License Number State |
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