Provider Demographics
NPI:1467450502
Name:OTA, TERESA
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:OTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27688
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0688
Mailing Address - Country:US
Mailing Address - Phone:801-534-1360
Mailing Address - Fax:801-366-9883
Practice Address - Street 1:3838 S 700 E
Practice Address - Street 2:STE 200
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-1466
Practice Address - Country:US
Practice Address - Phone:801-261-4988
Practice Address - Fax:801-269-9427
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT295818-1205207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD1177Medicaid
UTF35139Medicare UPIN