1417980939 NPI number — JOHN L OTIS M D & MICHELE A STEWART M D INC

Table of content: (NPI 1417980939)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417980939 NPI number — JOHN L OTIS M D & MICHELE A STEWART M D INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOHN L OTIS M D & MICHELE A STEWART M D INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417980939
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/22/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1679 E MAIN ST
Provider Second Line Business Mailing Address:
205
Provider Business Mailing Address City Name:
EL CAJON
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92021-5212
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-579-8745
Provider Business Mailing Address Fax Number:
619-457-2194

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4150 REGENTS PARK ROW
Provider Second Line Business Practice Location Address:
250
Provider Business Practice Location Address City Name:
LA JOLLA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92037-9124
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-457-2180
Provider Business Practice Location Address Fax Number:
858-457-2194
Provider Enumeration Date:
07/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
OTIS
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
619-579-8745

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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