Healthcare Provider Details

I. General information

NPI: 1881767606
Provider Name (Legal Business Name): RANDOLPH OTTO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2202 S CEDAR ST STE 200
TACOMA WA
98405-2318
US

IV. Provider business mailing address

3402 S 18TH ST
TACOMA WA
98405-1903
US

V. Phone/Fax

Practice location:
  • Phone: 253-383-1099
  • Fax: 253-383-3919
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License Number00027380
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: