Healthcare Provider Details

I. General information

NPI: 1053422378
Provider Name (Legal Business Name): ICHIRO OTSU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 S 43RD ST
RENTON WA
98055-5714
US

IV. Provider business mailing address

PO BOX 84571
SEATTLE WA
98124-5871
US

V. Phone/Fax

Practice location:
  • Phone: 425-353-3788
  • Fax: 425-353-8041
Mailing address:
  • Phone: 425-353-3788
  • Fax: 425-353-8041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD00038794
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: