Provider Demographics
NPI:1992760557
Name:OTHEGUY, JUAN (MD)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:
Last Name:OTHEGUY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2075 LITTLE RD
Mailing Address - Street 2:
Mailing Address - City:TRINITY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-4421
Mailing Address - Country:US
Mailing Address - Phone:727-375-5520
Mailing Address - Fax:727-375-1463
Practice Address - Street 1:2075 LITTLE RD
Practice Address - Street 2:
Practice Address - City:TRINITY
Practice Address - State:FL
Practice Address - Zip Code:34655-4421
Practice Address - Country:US
Practice Address - Phone:727-375-5520
Practice Address - Fax:727-375-1463
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-18
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME-62352174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF30305Medicare UPIN
FL15167YMedicare PIN