Healthcare Provider Details

I. General information

NPI: 1871550780
Provider Name (Legal Business Name): DERON C. K. OTTEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 12/06/2024
Certification Date: 12/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 E 19TH ST
ROSWELL NM
88201-5110
US

IV. Provider business mailing address

115 E 19TH ST
ROSWELL NM
88201-5110
US

V. Phone/Fax

Practice location:
  • Phone: 575-622-7600
  • Fax:
Mailing address:
  • Phone: 575-622-7600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD2024-1070
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberME112364
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: