1750336582 NPI number — TODD OTTESON M.D.

Table of content: TODD OTTESON M.D. (NPI 1750336582)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750336582 NPI number — TODD OTTESON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OTTESON
Provider First Name:
TODD
Provider Middle Name:
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:
1750336582
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/02/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24701 EUCLID AVE
Provider Second Line Business Mailing Address:
3RD FLOOR
Provider Business Mailing Address City Name:
EUCLID
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44117-1714
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11100 EUCLID AVE
Provider Second Line Business Practice Location Address:
LAKESIDE, ROOM 4527
Provider Business Practice Location Address City Name:
CLEVELAND
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44106-1716
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-844-3002
Provider Business Practice Location Address Fax Number:
216-201-4667
Provider Enumeration Date:
05/23/2006

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: 207Y00000X , with the licence number:  MD424615 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Y00000X , with the licence number: 35.120989 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 35.120989 . This is a "LICENSE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2658799 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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