Provider Demographics
NPI:1184719445
Name:OTTO, DEAN (MD)
Entity type:Individual
Prefix:
First Name:DEAN
Middle Name:
Last Name:OTTO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12265 TOWNSEND ROAD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19154
Mailing Address - Country:US
Mailing Address - Phone:215-856-1010
Mailing Address - Fax:215-698-3730
Practice Address - Street 1:100 MEDICAL CAMPUS DR
Practice Address - Street 2:
Practice Address - City:LANSDALE
Practice Address - State:PA
Practice Address - Zip Code:19446-1259
Practice Address - Country:US
Practice Address - Phone:215-361-4440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD058541-L207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
960306OtherABEM
PAMD058541-LOtherSTATE LICENSE
PAMD058541-LOtherSTATE LICENSE
G21059Medicare UPIN