Healthcare Provider Details

I. General information

NPI: 1477677557
Provider Name (Legal Business Name): STAVROULA ANASTASIA OTIS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STEVIE ANN OTIS M.D.

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 01/23/2024
Certification Date: 01/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

363 S MAIN ST STE 485
ORANGE CA
92868-3833
US

IV. Provider business mailing address

363 S MAIN ST STE 485
ORANGE CA
92868-3833
US

V. Phone/Fax

Practice location:
  • Phone: 714-835-4800
  • Fax:
Mailing address:
  • Phone: 714-835-4800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberA100358
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: