Healthcare Provider Details

I. General information

NPI: 1528059078
Provider Name (Legal Business Name): LARRY A. OTTEMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 08/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 DUFF AVE
AMES IA
50010-3014
US

IV. Provider business mailing address

1111 DUFF AVE
AMES IA
50010-3014
US

V. Phone/Fax

Practice location:
  • Phone: 515-239-4401
  • Fax: 515-239-4791
Mailing address:
  • Phone: 515-239-4401
  • Fax: 515-239-4791

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number24794
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: