Provider Demographics
NPI:1083619472
Name:OTT, MICHAEL ROBERT (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ROBERT
Last Name:OTT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4402 SHIPYARD BLVD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-6161
Mailing Address - Country:US
Mailing Address - Phone:910-452-1400
Mailing Address - Fax:910-332-1032
Practice Address - Street 1:4402 SHIPYARD BLVD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6161
Practice Address - Country:US
Practice Address - Phone:910-452-1400
Practice Address - Fax:910-332-1032
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200000925207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1266COtherBCBS
SCQ0092AMedicaid
NC930102882OtherRAILROAD MEDICARE
NC39-00201OtherUNITED HEALTHCARE
NC930104564OtherRAILROAD MEDICARE
NC891266CMedicaid
NCB4655OtherMEDCOST
NC2401178BMedicare PIN
NC930104564OtherRAILROAD MEDICARE
NC2401178AMedicare PIN