Provider Demographics
NPI:1326688995
Name:OTIS, CAROL L (MD)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:L
Last Name:OTIS
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 1:0836 SW CURRY ST UNIT 1400
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-4529
Mailing Address - Country:US
Mailing Address - Phone:310-704-9796
Mailing Address - Fax:
Practice Address - Street 1:0836 SW CURRY ST UNIT 1400
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-4529
Practice Address - Country:US
Practice Address - Phone:310-704-9796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-13
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG39461207RS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports Medicine