Provider Demographics
NPI:1508993064
Name:OTTO, WALTER C (PHD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:C
Last Name:OTTO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 COURTNEY LN
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89107-2429
Mailing Address - Country:US
Mailing Address - Phone:702-363-2336
Mailing Address - Fax:702-877-3874
Practice Address - Street 1:1750 S RAINBOW BLVD STE 2
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-2949
Practice Address - Country:US
Practice Address - Phone:702-363-2336
Practice Address - Fax:702-877-3874
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVA-138231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV35861Medicare ID - Type Unspecified
NVS02554Medicare UPIN