Healthcare Provider Details

I. General information

NPI: 1114969185
Provider Name (Legal Business Name): BRADLEY A. OTTO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 02/09/2021
Certification Date: 02/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 OLENTANGY RIVER RD STE 4000
COLUMBUS OH
43212-3154
US

IV. Provider business mailing address

700 ACKERMAN RD STE 2120
COLUMBUS OH
43202-1559
US

V. Phone/Fax

Practice location:
  • Phone: 614-366-3687
  • Fax: 614-293-6176
Mailing address:
  • Phone: 614-293-2594
  • Fax: 614-293-4487

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number35084019
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number35084019
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: