Provider Demographics
NPI:1184655904
Name:OTIS, MATTHEW MICHAEL (DO)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:MICHAEL
Last Name:OTIS
Suffix:
Gender:M
Credentials:DO
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 424
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50302-0424
Mailing Address - Country:US
Mailing Address - Phone:515-875-9255
Mailing Address - Fax:515-875-9223
Practice Address - Street 1:1410 SW TRADITION DR
Practice Address - Street 2:STE 110
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50023
Practice Address - Country:US
Practice Address - Phone:515-875-9696
Practice Address - Fax:515-875-9697
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IADO-03731207Q00000X
IAR7590390200000X
IA3731207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2736009Medicaid
IA1184655904Medicaid
IA2736009Medicaid