Provider Demographics
NPI:1437291697
Name:OTTO, WILLIAM J (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:J
Last Name:OTTO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:
Practice Address - Street 1:3231 S NATIONAL AVE
Practice Address - Street 2:SUITE 250
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-7304
Practice Address - Country:US
Practice Address - Phone:417-885-0828
Practice Address - Fax:417-886-7383
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOR3F74207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR113722001Medicaid
MO202187662Medicaid
AR81484OtherARK BLUE SHIELD
MO4594OtherMO BLUE SHIELD
A11707Medicare UPIN
AR81484OtherARK BLUE SHIELD