Provider Demographics
NPI:1477654820
Name:OTT, THOMAS EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:EDWARD
Last Name:OTT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17674 OTSEGO PIKE
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402-9723
Mailing Address - Country:US
Mailing Address - Phone:419-350-2430
Mailing Address - Fax:
Practice Address - Street 1:3030 W SYLVANIA AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43613-4100
Practice Address - Country:US
Practice Address - Phone:419-473-6615
Practice Address - Fax:419-291-6475
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35066600207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0101893Medicaid
OH607055OtherBCHP
MI104508050Medicaid
OH000000201372OtherANTHEM
OH01823OtherPARAMOUNT
OH080171614OtherRAILROAD MEDICARE
OH080171614OtherRAILROAD MEDICARE
MI104508050Medicaid
OH080171614OtherRAILROAD MEDICARE