Provider Demographics
NPI:1295816148
Name:SULLESTA, OTONIEL R (MD)
Entity Type:Individual
Prefix:DR
First Name:OTONIEL
Middle Name:R
Last Name:SULLESTA
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 1:411 N CANYON
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:NM
Mailing Address - Zip Code:88220
Mailing Address - Country:US
Mailing Address - Phone:575-887-0323
Mailing Address - Fax:575-887-8018
Practice Address - Street 1:2430 W PIERCE ST
Practice Address - Street 2:CARLSBAD MEDICAL CENTER
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220
Practice Address - Country:US
Practice Address - Phone:575-887-4150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM823192085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM28902Medicaid
E07872Medicare UPIN
NM346732501Medicare PIN
NM2135522HMedicare ID - Type Unspecified