Provider Demographics
NPI:1114065612
Name:PAYNE, OTIS EDD (MD)
Entity Type:Individual
Prefix:
First Name:OTIS
Middle Name:EDD
Last Name:PAYNE
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 1:18015 53RD AVE NE
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST PARK
Mailing Address - State:WA
Mailing Address - Zip Code:98155
Mailing Address - Country:US
Mailing Address - Phone:206-427-2171
Mailing Address - Fax:
Practice Address - Street 1:21810 76TH AVE WEST
Practice Address - Street 2:STE 202
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026
Practice Address - Country:US
Practice Address - Phone:206-427-2171
Practice Address - Fax:425-670-8293
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000105872084P0800X
LAMD0099592084P0800X
IN01034937A2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1199009Medicaid
WA1199009Medicaid
WA8801579Medicare ID - Type Unspecified