Healthcare Provider Details

I. General information

NPI: 1891865705
Provider Name (Legal Business Name): JOHN C OTTENBACHER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 09/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8001 WEST 5TH STREET
BOWDLE SD
57428
US

IV. Provider business mailing address

PO BOX 157
SELBY SD
57472-0157
US

V. Phone/Fax

Practice location:
  • Phone: 605-285-9832
  • Fax: 605-285-6986
Mailing address:
  • Phone: 605-649-7366
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1128
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: