Healthcare Provider Details

I. General information

NPI: 1629075429
Provider Name (Legal Business Name): VICTORIA ANN OTHERSEN D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VICTONIA ANN PIEKARSKI D.O.

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 04/11/2024
Certification Date: 04/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

362 MERIDIAN PARKE LN STE A
GREENWOOD IN
46142-9425
US

IV. Provider business mailing address

PO BOX 781076
DETROIT MI
48278-1076
US

V. Phone/Fax

Practice location:
  • Phone: 317-528-8760
  • Fax: 317-528-8761
Mailing address:
  • Phone: 317-528-4800
  • Fax: 317-865-1479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34-007433
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02004084A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: