1841494689 NPI number — RANDALL JASON OTTO M.D.

Table of content: VALENCIA NYCOLE MILLER (NPI 1801585708)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841494689 NPI number — RANDALL JASON OTTO M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OTTO
Provider First Name:
RANDALL
Provider Middle Name:
JASON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1841494689
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/24/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1008 S SPRING AVE FL 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63110-2520
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-977-5350
Provider Business Mailing Address Fax Number:
314-977-1629

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1011 BOWLES AVE STE 400
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FENTON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63026-2387
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-977-7200
Provider Business Practice Location Address Fax Number:
636-326-6533
Provider Enumeration Date:
06/14/2007

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: 207X00000X , with the licence number:  2012011162 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 136637 . This is a "HEALTHCARE USA" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 4258558 . This is a "CIGNA" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 501357701 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 122950063 . This is a "MEDICARE PTAN" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: A82171 . This is a "HEALTHLINK" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 771091 . This is a "ANTHEM BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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