Provider Demographics
NPI:1164500302
Name:OTWAY, TONI M (MD)
Entity Type:Individual
Prefix:DR
First Name:TONI
Middle Name:M
Last Name:OTWAY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:TONI
Other - Middle Name:M
Other - Last Name:OTWAY-GRANNUM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1478 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-3915
Mailing Address - Country:US
Mailing Address - Phone:718-442-3434
Mailing Address - Fax:718-981-4578
Practice Address - Street 1:1478 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-3915
Practice Address - Country:US
Practice Address - Phone:718-442-3434
Practice Address - Fax:718-981-4578
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY216745207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02087763Medicaid
NYH19982Medicare UPIN
NY60N371Medicare ID - Type Unspecified