Healthcare Provider Details

I. General information

NPI: 1073705166
Provider Name (Legal Business Name): OTIS EDD PAYNE, M.D.,PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2007
Last Update Date: 08/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18015 53RD AVE NE
LAKE FOREST PARK WA
98155-4361
US

IV. Provider business mailing address

18015 53RD AVE NE
LAKE FOREST PARK WA
98155-4361
US

V. Phone/Fax

Practice location:
  • Phone: 206-427-2171
  • Fax: 425-670-8293
Mailing address:
  • Phone: 206-427-2171
  • Fax: 425-670-8293

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD00010587
License Number StateWA

VIII. Authorized Official

Name: DR. OTIS EDD PAYNE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 206-427-2171