Provider Demographics
NPI:1114969185
Name:OTTO, BRADLEY A (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:A
Last Name:OTTO
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 1:700 ACKERMAN RD STE 2120
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1559
Mailing Address - Country:US
Mailing Address - Phone:614-293-2594
Mailing Address - Fax:614-293-4487
Practice Address - Street 1:915 OLENTANGY RIVER RD STE 4000
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43212-3154
Practice Address - Country:US
Practice Address - Phone:614-366-3687
Practice Address - Fax:614-293-6176
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35084019208600000X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2539971Medicaid
OH2539971Medicaid