Provider Demographics
NPI:1093716797
Name:OTT, BENJAMIN THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:THOMAS
Last Name:OTT
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-637-3373
Mailing Address - Fax:705-637-0069
Practice Address - Street 1:650 JULIAN RD
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28147-9078
Practice Address - Country:US
Practice Address - Phone:704-637-3373
Practice Address - Fax:705-637-0069
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200400726207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1370YOtherBLUE CROSS BLUE SHIELD NC
NC891370YMedicaid
NC891370YMedicaid
NC2030647AMedicare PIN
NCI14664Medicare UPIN