MEDICARE: DR. THEODORE IKECHUKWU OTTI M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RN0300X	Nephrology Physician	103005	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1316950884
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THEODORE IKECHUKWU OTTI M.D.

Provider Business Mailing Address
First Line	:	PO BOX 4031
Second Line	:
City	:	CHESTERFIELD
State	:	MO
Zip	:	63006-4031
Country	:	US
Telephone Number	:	314-577-5778
Fax Number	:	636-939-1629

Provider Business Practice Location Address
First Line	:	1035 BELLEVUE AVE STE 315
Second Line	:
City	:	RICHMOND HEIGHTS
State	:	MO
Zip	:	63117-1856
Country	:	US
Telephone Number	:	314-683-6110
Fax Number	:	314-485-2136

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/14/2006
Last Update Date	:	07/21/2022

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