Provider Demographics
NPI:1326269945
Name:OTERI, DOMINIC LEONARD (MD)
Entity Type:Individual
Prefix:DR
First Name:DOMINIC
Middle Name:LEONARD
Last Name:OTERI
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 1:2100 KEYSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:DREXEL HILL
Mailing Address - State:PA
Mailing Address - Zip Code:19026
Mailing Address - Country:US
Mailing Address - Phone:610-394-9414
Mailing Address - Fax:
Practice Address - Street 1:2100 KEYSTONE AVE
Practice Address - Street 2:
Practice Address - City:DREXEL HILL
Practice Address - State:PA
Practice Address - Zip Code:19026
Practice Address - Country:US
Practice Address - Phone:610-394-9414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD055989L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G30757Medicare UPIN