Healthcare Provider Details

I. General information

NPI: 1003789322
Provider Name (Legal Business Name): RANDY KURT OTTO PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2025
Last Update Date: 11/17/2025
Certification Date: 11/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

FAMILY MEDICINE CENTER 2400 TUCKER AVE NE
ALBUQUERQUE NM
87131-0001
US

IV. Provider business mailing address

1 UNIVERSITY OF NEW MEXICO
ALBUQUERQUE NM
87131-0001
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-2800
  • Fax:
Mailing address:
  • Phone: 813-300-1484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY-2025-0065
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: