Provider Demographics
NPI:1417449083
Name:OTTENWALDER, GERALD MICHAEL (KCPM)
Entity Type:Individual
Prefix:MR
First Name:GERALD
Middle Name:MICHAEL
Last Name:OTTENWALDER
Suffix:
Gender:M
Credentials:KCPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 SHERMAN ST
Mailing Address - Street 2:
Mailing Address - City:EMPORIA
Mailing Address - State:KS
Mailing Address - Zip Code:66801-2401
Mailing Address - Country:US
Mailing Address - Phone:620-757-2661
Mailing Address - Fax:
Practice Address - Street 1:420 KENNEDY ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:KS
Practice Address - Zip Code:66839-1120
Practice Address - Country:US
Practice Address - Phone:620-364-2606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-30
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist