Provider Demographics
NPI:1497829907
Name:OTERO, RONNY M (MD)
Entity Type:Individual
Prefix:
First Name:RONNY
Middle Name:M
Last Name:OTERO
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 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-955-6450
Mailing Address - Fax:414-955-0082
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-955-6450
Practice Address - Fax:414-955-0082
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI76231207P00000X
MI4301069663207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RO069663OtherCOMMERCIAL-COMMERCIAL NUMBER
RO069663OtherCHAMPUS-CHAMPUS
010H262530OtherBLUE CROSS-BLUE CROSS
MI458069810Medicaid
H61377Medicare UPIN
RO069663OtherCOMMERCIAL-COMMERCIAL NUMBER