Provider Demographics
NPI:1346264215
Name:OTTO, RUSSELL R (PA)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:R
Last Name:OTTO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 BOSTON POST RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06385-2805
Mailing Address - Country:US
Mailing Address - Phone:860-442-0407
Mailing Address - Fax:604-442-0158
Practice Address - Street 1:201 BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:CT
Practice Address - Zip Code:06385
Practice Address - Country:US
Practice Address - Phone:860-442-0407
Practice Address - Fax:860-444-2015
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004505363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant