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General NPI Number Information
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NPI Number | 1619343019
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Entity Type | Organization
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Legal Business Name | OETTER FAMILY MEDICAL CORP
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Dates
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Enumeration Date | 08/19/2015
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Last Update Date | 08/19/2015
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Provider Practice Location Address
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Address Line | 401 WALL ST
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City | VALPARAISO
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State | IN
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Zip | 46383-2521
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Country | US
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Telephone | 219-281-1729
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Fax |
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Provider Business Mailing Address
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Address Line | 401 WALL ST SUITE B
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City | VALPARAISO
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State | IN
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Zip | 46383-2521
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Country | US
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Telephone | 219-281-1729
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Fax |
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Authorized Official
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Title or Position | PHYSICIAN
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Name | KENDELL LYNN OETTER
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Credential | M.D.
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Telephone | 219-789-6704
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 02001332A
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License Number State | IN
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