Provider Demographics
NPI:1154475770
Name:OTTLEY, ROLAND GODFREY (PA)
Entity Type:Individual
Prefix:
First Name:ROLAND
Middle Name:GODFREY
Last Name:OTTLEY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:585 SCHENECTADY AVE
Mailing Address - Street 2:DEPT. OF SURGERY
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-1809
Mailing Address - Country:US
Mailing Address - Phone:718-604-5421
Mailing Address - Fax:718-604-5527
Practice Address - Street 1:585 SCHENECTADY AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-1822
Practice Address - Country:US
Practice Address - Phone:718-604-5421
Practice Address - Fax:718-604-5527
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2009-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003792363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY4F9571Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID