Provider Demographics
NPI:1477637866
Name:OTTO, GARY (DC)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:
Last Name:OTTO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16911 E QUINCY AVE
Mailing Address - Street 2:A-3
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80015-6102
Mailing Address - Country:US
Mailing Address - Phone:303-766-7073
Mailing Address - Fax:
Practice Address - Street 1:16911 E QUINCY AVE
Practice Address - Street 2:A-3
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80015-6102
Practice Address - Country:US
Practice Address - Phone:303-766-7073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3665111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO3665OtherSTATE LICENSE
CO12963Medicare PIN
COU41636Medicare UPIN