Healthcare Provider Details

I. General information

NPI: 1568424661
Provider Name (Legal Business Name): SHIRLEY M. OTIS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2006
Last Update Date: 06/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10666 N TORREY PINES RD
LA JOLLA CA
92037-1027
US

IV. Provider business mailing address

FILE# 54433
LOS ANGELES CA
90074-0001
US

V. Phone/Fax

Practice location:
  • Phone: 858-554-8892
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberG14706
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: