Healthcare Provider Details

I. General information

NPI: 1972091866
Provider Name (Legal Business Name): KOJI OTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2018
Last Update Date: 04/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 E 17TH ST FL 20
NEW YORK NY
10003-3805
US

IV. Provider business mailing address

350 E 17TH ST FL 20
NEW YORK NY
10003-3805
US

V. Phone/Fax

Practice location:
  • Phone: 917-930-0243
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: