MEDICARE: DAVID THOMAS OTTENBAKER MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	4301047511	MI

General Provider Information

NPI Number	:	1386648624
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID THOMAS OTTENBAKER MD

Provider Business Mailing Address
First Line	:	100 MICHIGAN ST NE
Second Line	:	MC845
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49503-2560
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1445 SHELDON RD
Second Line	:	SUITE 201
City	:	GRAND HAVEN
State	:	MI
Zip	:	49417-2480
Country	:	US
Telephone Number	:	616-846-8540
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/01/2005
Last Update Date	:	01/24/2012

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