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General NPI Number Information
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NPI Number | 1295965176
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Entity Type | Individual
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Provider Name | MR. IAN SETH OTTO
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Gender | Male
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Dates
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Enumeration Date | 07/25/2009
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Last Update Date | 07/25/2009
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Provider Practice Location Address
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Address Line | 13400 SUTTON PARK DR S SUITE 1101
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City | JACKSONVILLE
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State | FL
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Zip | 32224-0236
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Country | US
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Telephone | 904-254-8713
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Fax |
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Provider Business Mailing Address
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Address Line | 13525 VALBUENA CT
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City | JACKSONVILLE
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State | FL
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Zip | 32224-3087
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Country | US
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Telephone | 904-536-4962
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | 26-4600206
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License Number State | FL
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