Provider Demographics
NPI:1033138110
Name:OWENS, OTHELLA THERESA (MD)
Entity Type:Individual
Prefix:DR
First Name:OTHELLA
Middle Name:THERESA
Last Name:OWENS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1127 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 1604
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-4007
Mailing Address - Country:US
Mailing Address - Phone:213-250-5470
Mailing Address - Fax:213-250-5468
Practice Address - Street 1:1127 WILSHIRE BLVD
Practice Address - Street 2:SUITE 1604
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-4007
Practice Address - Country:US
Practice Address - Phone:213-250-5470
Practice Address - Fax:213-250-5468
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG42573207YX0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G425730Medicaid
CA00G425730Medicaid
CAG4273BMedicare ID - Type Unspecified