1629075429 NPI number — DR. VICTORIA ANN OTHERSEN D.O.

Table of content: DR. VICTORIA ANN OTHERSEN D.O. (NPI 1629075429)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629075429 NPI number — DR. VICTORIA ANN OTHERSEN D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OTHERSEN
Provider First Name:
VICTORIA
Provider Middle Name:
ANN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PIEKARSKI
Provider Other First Name:
VICTONIA
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
D.O.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1629075429
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/29/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2030 CHURCHMAN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEECH GROVE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46107-1044
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-786-9285
Provider Business Mailing Address Fax Number:
317-781-2793

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2030 CHURCHMAN AVE # A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEECH GROVE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46107
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-786-9285
Provider Business Practice Location Address Fax Number:
317-781-2793
Provider Enumeration Date:
07/07/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  34-007433 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 02004084A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200250180A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000522568 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".