Provider Demographics
NPI:1386627867
Name:OTTUSO, PATRICK THOMAS (M D F A A D)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:THOMAS
Last Name:OTTUSO
Suffix:
Gender:M
Credentials:M D F A A D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1955 22ND AVE
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-3083
Mailing Address - Country:US
Mailing Address - Phone:772-299-0085
Mailing Address - Fax:772-978-4193
Practice Address - Street 1:1955 22ND AVE
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-3083
Practice Address - Country:US
Practice Address - Phone:772-299-0085
Practice Address - Fax:772-978-4193
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-29
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME62353207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL070015813OtherRR MEDICARE
FL9614490OtherGHI
FL18397OtherBLUE CROSS
FLF44730Medicare UPIN
FL18397Medicare PIN