Healthcare Provider Details

I. General information

NPI: 1164354320
Provider Name (Legal Business Name): EZRA OTTO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2026
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2750 W NORTH AVE
CHICAGO IL
60647-5247
US

IV. Provider business mailing address

2750 W NORTH AVE
CHICAGO IL
60647-5247
US

V. Phone/Fax

Practice location:
  • Phone: 312-666-3494
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number041.606821
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: