Provider Demographics
NPI:1124133343
Name:OTERO, ANGELES IVETTE (MD)
Entity type:Individual
Prefix:DR
First Name:ANGELES
Middle Name:IVETTE
Last Name:OTERO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:ANGELES
Other - Middle Name:IVETTE
Other - Last Name:CARRASQUILLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:706 E GRAND HWY
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-3708
Mailing Address - Country:US
Mailing Address - Phone:352-557-4965
Mailing Address - Fax:352-404-6955
Practice Address - Street 1:706 E GRAND HWY
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-3708
Practice Address - Country:US
Practice Address - Phone:352-557-4965
Practice Address - Fax:352-404-6955
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME89425208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL274654900Medicaid