=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467447623
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | OTTO R. DUENO M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2005
-----------------------------------------------------
Last Update Date | 04/06/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 ELIZABETH PL SUITE G-3
-----------------------------------------------------
City | DAYTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45417-3445
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-281-0900
-----------------------------------------------------
Fax | 937-281-0930
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1748 CEDAR RIDGE DR
-----------------------------------------------------
City | SPRING VALLEY
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45370-9783
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-848-3729
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 35066509
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------