Provider Demographics
NPI:1730378142
Name:JAMES OTTO, M.D., P.A.
Entity type:Organization
Organization Name:JAMES OTTO, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:HAGEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-203-2882
Mailing Address - Street 1:3734 GARAND RD.
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042
Mailing Address - Country:US
Mailing Address - Phone:410-465-6186
Mailing Address - Fax:
Practice Address - Street 1:8835 COLUMBIA 100 PARKWAY
Practice Address - Street 2:SUITE N
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-2147
Practice Address - Country:US
Practice Address - Phone:410-997-0909
Practice Address - Fax:410-997-0504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-22
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD39178207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD823MMedicare PIN
MD823M436FMedicare PIN