Healthcare Provider Details

I. General information

NPI: 1124054101
Provider Name (Legal Business Name): BRIAN R OTT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 03/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 EDDY ST APC 6
PROVIDENCE RI
02903-4923
US

IV. Provider business mailing address

1 HOPPIN ST SUITE 318
PROVIDENCE RI
02903-4141
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-4000
  • Fax:
Mailing address:
  • Phone: 401-793-8382
  • Fax: 401-793-8312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD05819
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberMD05819
License Number StateRI
# 3
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberMD05819
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: