Provider Demographics
NPI:1285920363
Name:COTELO LLC
Entity type:Organization
Organization Name:COTELO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DAMIAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:DIAZ COTELO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:786-474-4345
Mailing Address - Street 1:11767 S DIXIE HWY
Mailing Address - Street 2:423
Mailing Address - City:PINECREST
Mailing Address - State:FL
Mailing Address - Zip Code:33156-4438
Mailing Address - Country:US
Mailing Address - Phone:786-474-4345
Mailing Address - Fax:855-268-3561
Practice Address - Street 1:11767 S DIXIE HWY
Practice Address - Street 2:423
Practice Address - City:PINECREST
Practice Address - State:FL
Practice Address - Zip Code:33156-4438
Practice Address - Country:US
Practice Address - Phone:786-474-4345
Practice Address - Fax:855-268-3561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-27
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME105957207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME105957OtherMEDICAL LICENSE