Healthcare Provider Details

I. General information

NPI: 1659799161
Provider Name (Legal Business Name): ELIZABETH A. OTMASKIN D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2014
Last Update Date: 09/16/2020
Certification Date: 09/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3455 MAIN STREET SUITE C BAYSTTATE OB GYN GROUP INC
SPRINGFIELD MA
01107
US

IV. Provider business mailing address

3455 MAIN ST STE C
SPRINGFIELD MA
01107-1187
US

V. Phone/Fax

Practice location:
  • Phone: 413-794-8484
  • Fax: 413-794-8477
Mailing address:
  • Phone: 413-794-8484
  • Fax: 413-479-4184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number274604
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: