Basic Information
| Provider Information | |||||||||
| NPI: | 1992771273 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OTTAVIANI | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | B | ||||||||
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| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 8000 SR 64 E | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 34212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417921404 | ||||||||
| FaxNumber: | 9417951717 | ||||||||
| Practice Location | |||||||||
| Address1: | 8000 SR 64 E | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 34212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417921404 | ||||||||
| FaxNumber: | 9417951717 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2006 | ||||||||
| LastUpdateDate: | 05/25/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 05/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | OS 7921 | FL | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 46759 | 01 | FL | BCBS FL | OTHER | 1285740720 | 01 | FL | GROUP NPI | OTHER | 260048612 | 01 | FL | RAILROAD MEDICARE | OTHER |