Healthcare Provider Details

I. General information

NPI: 1639129380
Provider Name (Legal Business Name): STACIE MICHELLE OTTEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 07/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 W 38TH ST
AUSTIN TX
78705-1006
US

IV. Provider business mailing address

2619 DEERFOOT TRL
AUSTIN TX
78704-2715
US

V. Phone/Fax

Practice location:
  • Phone: 512-324-1010
  • Fax:
Mailing address:
  • Phone: 512-633-4028
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberK5171
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: