Healthcare Provider Details

I. General information

NPI: 1306847900
Provider Name (Legal Business Name): OTIS GEORGE ALLEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2005
Last Update Date: 08/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 HOLIDAY DR
BLOOMINGTON IL
61704-2214
US

IV. Provider business mailing address

53 PRENZLER DR
BLOOMINGTON IL
61704-1299
US

V. Phone/Fax

Practice location:
  • Phone: 309-827-3881
  • Fax: 309-661-0234
Mailing address:
  • Phone: 309-287-8049
  • Fax: 309-661-0234

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number036064804
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: