1275523276 NPI number — TODD M OTSTOT PA-C

Table of content: TODD M OTSTOT PA-C (NPI 1275523276)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275523276 NPI number — TODD M OTSTOT PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OTSTOT
Provider First Name:
TODD
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
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:
1275523276
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/06/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
206 E ELM ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CALDWELL
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83605-4815
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-459-4511
Provider Business Mailing Address Fax Number:
208-459-6602

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
206 E ELM ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CALDWELL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83605-4815
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-459-4511
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/21/2005

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: 363A00000X , with the licence number:  PA-356 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA356 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: PA-356 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000010035293 . This is a "BLUE SHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 970022197 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 806153700 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000010035292 . This is a "BLUE SHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: PAA02 . This is a "BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: PAAE9 . This is a "BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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