Provider Demographics
NPI:1306915335
Name:OTTO, NICOLE (MD)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:
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 1:213 DICKINSON AVE
Mailing Address - Street 2:
Mailing Address - City:SWARTHMORE
Mailing Address - State:PA
Mailing Address - Zip Code:19081-1630
Mailing Address - Country:US
Mailing Address - Phone:610-328-2892
Mailing Address - Fax:
Practice Address - Street 1:3535 MARKET ST
Practice Address - Street 2:SUITE 100
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-3309
Practice Address - Country:US
Practice Address - Phone:215-746-3535
Practice Address - Fax:215-746-1032
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2009-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD425787207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine