Provider Demographics
NPI:1265669410
Name:OTTO, KRISTEN JOHNSON (MD)
Entity Type:Individual
Prefix:DR
First Name:KRISTEN
Middle Name:JOHNSON
Last Name:OTTO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12902 USF MAGNOLIA DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-9416
Mailing Address - Country:US
Mailing Address - Phone:813-745-8363
Mailing Address - Fax:813-745-3830
Practice Address - Street 1:12902 USF MAGNOLIA DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-9416
Practice Address - Country:US
Practice Address - Phone:813-745-8363
Practice Address - Fax:813-745-3830
Is Sole Proprietor?:No
Enumeration Date:2009-06-15
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS20640207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00785270OtherM'CARE RR
P00785270OtherM'CARE RR
P00785270OtherM'CARE RR