Provider Demographics
NPI:1073705166
Name:OTIS EDD PAYNE, M.D.,PS
Entity Type:Organization
Organization Name:OTIS EDD PAYNE, M.D.,PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:OTIS
Authorized Official - Middle Name:EDD
Authorized Official - Last Name:PAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:206-427-2171
Mailing Address - Street 1:18015 53RD AVE NE
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST PARK
Mailing Address - State:WA
Mailing Address - Zip Code:98155-4361
Mailing Address - Country:US
Mailing Address - Phone:206-427-2171
Mailing Address - Fax:425-670-8293
Practice Address - Street 1:18015 53RD AVE NE
Practice Address - Street 2:
Practice Address - City:LAKE FOREST PARK
Practice Address - State:WA
Practice Address - Zip Code:98155-4361
Practice Address - Country:US
Practice Address - Phone:206-427-2171
Practice Address - Fax:425-670-8293
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-13
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000105872084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1199009Medicaid
WAG8801577OtherMEDICARE GROUP