Healthcare Provider Details

I. General information

NPI: 1518954999
Provider Name (Legal Business Name): MAYUMI OTSUKA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 04/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 EAST NIZHONI BLVD
GALLUP NM
87301-1337
US

IV. Provider business mailing address

P.O. BOX 1337
GALLUP NM
87305-1337
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-1000
  • Fax: 505-722-1268
Mailing address:
  • Phone: 505-722-1000
  • Fax: 505-722-1268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0420010593
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: