Provider Demographics
NPI:1497749162
Name:OTTO, SCOTT C (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:C
Last Name:OTTO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 800022
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-0022
Mailing Address - Country:US
Mailing Address - Phone:800-953-0104
Mailing Address - Fax:303-765-6670
Practice Address - Street 1:11700 W 2ND PL STE 210
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80228-1716
Practice Address - Country:US
Practice Address - Phone:720-321-8080
Practice Address - Fax:720-321-8081
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036109065208600000X
CODR.0066919208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036109065Medicaid
CO9000199569Medicaid