Healthcare Provider Details

I. General information

NPI: 1730266420
Provider Name (Legal Business Name): RICHARD ELMER OTTO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

908 ROCKMOOR DR
GEORGETOWN TX
78628-8966
US

IV. Provider business mailing address

908 ROCKMOOR DR
GEORGETOWN TX
78628-8966
US

V. Phone/Fax

Practice location:
  • Phone: 512-868-0901
  • Fax: 512-868-1527
Mailing address:
  • Phone: 512-868-0901
  • Fax: 512-868-1527

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberL9409
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: