Healthcare Provider Details

I. General information

NPI: 1164478293
Provider Name (Legal Business Name): OTTER CREEK MEDICAL OFFICE, LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 11/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 ELM ST
MC GRAW NY
13101-9471
US

IV. Provider business mailing address

2 ELM ST
MC GRAW NY
13101-9471
US

V. Phone/Fax

Practice location:
  • Phone: 607-836-7540
  • Fax: 607-836-4180
Mailing address:
  • Phone: 607-836-7540
  • Fax: 607-836-4180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number187190
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number000148
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number186955
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. MARY THERESE MASTRUCCI
Title or Position: PARTNER
Credential: M.D.
Phone: 607-756-0709