Healthcare Provider Details

I. General information

NPI: 1922583533
Provider Name (Legal Business Name): OTEL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2018
Last Update Date: 04/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9621 CORONADO AVE NE
ALBUQUERQUE NM
87122-3363
US

IV. Provider business mailing address

DEPT.880271 PO BOX 29650
PHOENIX AZ
85038-9650
US

V. Phone/Fax

Practice location:
  • Phone: 800-310-7334
  • Fax:
Mailing address:
  • Phone: 800-310-7334
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204R00000X
TaxonomyElectrodiagnostic Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ERNESTO R OTERO-LOPEZ
Title or Position: SOLE MBR
Credential: MD
Phone: 800-310-7334