Provider Demographics
NPI:1326005745
Name:OETOMO, INDRA SOERJA (PT, LAC)
Entity Type:Individual
Prefix:MR
First Name:INDRA
Middle Name:SOERJA
Last Name:OETOMO
Suffix:
Gender:M
Credentials:PT, LAC
Other - Prefix:MR
Other - First Name:RORY
Other - Middle Name:
Other - Last Name:OETOMO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT, LAC
Mailing Address - Street 1:8955 S RIDGELINE BLVD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:HIGHLANDS RANCH
Mailing Address - State:CO
Mailing Address - Zip Code:80129-2362
Mailing Address - Country:US
Mailing Address - Phone:303-683-8338
Mailing Address - Fax:303-683-8809
Practice Address - Street 1:8955 S RIDGELINE BLVD
Practice Address - Street 2:SUITE 400
Practice Address - City:HIGHLANDS RANCH
Practice Address - State:CO
Practice Address - Zip Code:80129-2362
Practice Address - Country:US
Practice Address - Phone:303-683-8338
Practice Address - Fax:303-683-8809
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO978171100000X
CO35792251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered171100000XOther Service ProvidersAcupuncturist
Not Answered2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO25733Medicare ID - Type Unspecified