MEDICARE: DR. WILLIAM ENRIQUE OTERO M.D.

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	036 102552	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	01626950	OTHER	IL	BLUE CROSS BLUE SHIELD
3	36 4385201	OTHER	IL	TAX IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1588776884
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WILLIAM ENRIQUE OTERO M.D.

Provider Business Mailing Address
First Line	:	4911 W FULLERTON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60639-2505
Country	:	US
Telephone Number	:	773-772-4900
Fax Number	:	773-772-0298

Provider Business Practice Location Address
First Line	:	2363 N CALIFORNIA AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-2939
Country	:	US
Telephone Number	:	773-772-4900
Fax Number	:	773-772-0298

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

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	03/18/2019

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