Provider Demographics
NPI:1306847900
Name:ALLEN, OTIS GEORGE (MD)
Entity Type:Individual
Prefix:DR
First Name:OTIS
Middle Name:GEORGE
Last Name:ALLEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:53 PRENZLER DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-1299
Mailing Address - Country:US
Mailing Address - Phone:309-287-8049
Mailing Address - Fax:309-661-0234
Practice Address - Street 1:1215 HOLIDAY DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-2214
Practice Address - Country:US
Practice Address - Phone:309-827-3881
Practice Address - Fax:309-661-0234
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036064804208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036064804Medicaid
IL691890Medicare PIN
ILD14977Medicare UPIN