Healthcare Provider Details

I. General information

NPI: 1215963509
Provider Name (Legal Business Name): PATRICIA SUE OTIS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 02/04/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1049 EDGEWATER ST NW # 150
SALEM OR
97304-4046
US

IV. Provider business mailing address

1049 EDGEWATER ST NW STE 150
SALEM OR
97304-4046
US

V. Phone/Fax

Practice location:
  • Phone: 503-814-4400
  • Fax: 503-814-4414
Mailing address:
  • Phone: 503-814-4400
  • Fax: 503-814-4414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number23396
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD27752
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: