Provider Demographics
NPI:1174767776
Name:OTREMBA, JOHN A (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:OTREMBA
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1560 E MAPLE RD
Mailing Address - Street 2:SUITE 400-CREDENTIALING
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1138
Mailing Address - Country:US
Mailing Address - Phone:248-650-6301
Mailing Address - Fax:248-650-5486
Practice Address - Street 1:1135 W UNIVERSITY DR
Practice Address - Street 2:SUITE 250
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48307-1886
Practice Address - Country:US
Practice Address - Phone:248-650-6301
Practice Address - Fax:248-650-5486
Is Sole Proprietor?:No
Enumeration Date:2009-04-27
Last Update Date:2016-10-27
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Provider Licenses
StateLicense IDTaxonomies
MI4301101787207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P30630836Medicare PIN