Healthcare Provider Details

I. General information

NPI: 1275920142
Provider Name (Legal Business Name): LAURA OTIS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2015
Last Update Date: 12/02/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 E CESAR E CHAVEZ AVE
LOS ANGELES CA
90033-2414
US

IV. Provider business mailing address

1720 E CESAR E CHAVEZ AVE
LOS ANGELES CA
90033-2414
US

V. Phone/Fax

Practice location:
  • Phone: 858-436-6837
  • Fax:
Mailing address:
  • Phone: 858-436-6837
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number135589
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: