Provider Demographics
NPI:1124759741
Name:KEROLLOS, KEROLLOS MOTWADE
Entity type:Individual
Prefix:
First Name:KEROLLOS
Middle Name:MOTWADE
Last Name:KEROLLOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:636 DEL PRADO BLVD
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33990-2695
Mailing Address - Country:US
Mailing Address - Phone:708-202-5064
Mailing Address - Fax:
Practice Address - Street 1:636 DEL PRADO BLVD S
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-2695
Practice Address - Country:US
Practice Address - Phone:239-424-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-23
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125079466207RG0300X
FL36859207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine