Healthcare Provider Details

I. General information

NPI: 1790705283
Provider Name (Legal Business Name): ROGER KEITH OTTMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1512 12TH AVE RD
NAMPA ID
83686-6008
US

IV. Provider business mailing address

1100 RIVER HEIGHTS DR
MERIDIAN ID
83642-5166
US

V. Phone/Fax

Practice location:
  • Phone: 208-463-5100
  • Fax:
Mailing address:
  • Phone: 208-841-1814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberM-3812
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: