Healthcare Provider Details

I. General information

NPI: 1154642551
Provider Name (Legal Business Name): HEATHER OTTMERS CADDELL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HEATHER OTTMERS

II. Dates (important events)

Enumeration Date: 06/20/2010
Last Update Date: 07/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 E BANDERA RD SUITE 204
BOERNE TX
78006-2849
US

IV. Provider business mailing address

1355 CENTRAL PKWY S SUITE 400
SAN ANTONIO TX
78232-5055
US

V. Phone/Fax

Practice location:
  • Phone: 210-653-5501
  • Fax: 210-650-5975
Mailing address:
  • Phone: 210-590-6195
  • Fax: 210-650-5993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberP9817
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: