Healthcare Provider Details

I. General information

NPI: 1235154535
Provider Name (Legal Business Name): JOHN LEE OTIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 09/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4150 REGENTS PARK ROW 250
LA JOLLA CA
92037-9124
US

IV. Provider business mailing address

1679 E MAIN ST 205
EL CAJON CA
92021-5212
US

V. Phone/Fax

Practice location:
  • Phone: 858-457-2180
  • Fax: 858-457-2194
Mailing address:
  • Phone: 619-579-8745
  • Fax: 619-457-2194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberG28506
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: