Provider Demographics
NPI:1992925051
Name:OTERO, WILSON NICOLAS (MD)
Entity type:Individual
Prefix:DR
First Name:WILSON
Middle Name:NICOLAS
Last Name:OTERO
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 1:12400 SW 1ST CT
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33325-2702
Mailing Address - Country:US
Mailing Address - Phone:954-483-8335
Mailing Address - Fax:
Practice Address - Street 1:9149 ESTATE THOMAS
Practice Address - Street 2:PARAGON MEDICAL BUILDING SUITE 208
Practice Address - City:ST. THOMAS
Practice Address - State:VI
Practice Address - Zip Code:00802-2615
Practice Address - Country:US
Practice Address - Phone:340-714-1122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-30
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ44063174400000X, 207RG0100X
VI3572207RG0100X
WAMD00030353207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1025558OtherCAREPLUS PROVIDER ID #
FL4073765OtherAETNA NETWORK ID NUMBER
FL020549565OtherHUMANA HTLH INS ID #
FL28885OtherSTAYWELL HLTH PLANS ID #
FL28885OtherWELLCARE PROVIDER ID #
FL96681OtherBLUE CROSS BLUE SHIELD FL
FL040931600Medicaid
FL28885OtherHEALTHEASE HLTH PLANS ID#
AZ582847Medicaid
FL33648OtherNEIGHBORHOOD HTLH PLAN ID
FL020549565OtherUNITED HTLHCARE ID #
FL020549565OtherCIGNA PPO ID NUMBER
FL237645OtherAVMED PROVIDER ID #
FL104531OtherMEMORIAL MANAGED CARE ID
FL59257OtherVISTA HEALTH PLAN ID #
FL104531OtherMEMORIAL MANAGED CARE ID
FL28885OtherSTAYWELL HLTH PLANS ID #
FL040931600Medicaid
AZZ142775Medicare PIN