Provider Demographics
NPI:1417600891
Name:OTTEY BONE AND JOINT MEDICAL ASSOCIATE, PLLC
Entity Type:Organization
Organization Name:OTTEY BONE AND JOINT MEDICAL ASSOCIATE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DERON
Authorized Official - Middle Name:CK
Authorized Official - Last Name:OTTEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-517-0943
Mailing Address - Street 1:602 SCHENECTADY AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-1821
Mailing Address - Country:US
Mailing Address - Phone:718-517-0943
Mailing Address - Fax:904-368-0643
Practice Address - Street 1:602 SCHENECTADY AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-1821
Practice Address - Country:US
Practice Address - Phone:718-517-0943
Practice Address - Fax:904-368-0643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-27
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY12353227OtherCAQH
NY234872OtherMEDICAL LICENSE