Basic Information
| Provider Information | |||||||||
| NPI: | 1124599824 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRESTIGE OUTPATIENT PROVIDERS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2338 IMMOKALEE RD # 141 | ||||||||
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| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341101445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393302933 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2338 IMMOKALEE RD # 186 | ||||||||
| Address2: | |||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341101445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393302933 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2018 | ||||||||
| LastUpdateDate: | 12/21/2018 | ||||||||
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| AuthorizedOfficialLastName: | RUSTAMOVA | ||||||||
| AuthorizedOfficialFirstName: | OKSANA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 6465171257 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.