Provider Demographics
NPI:1548234636
Name:R OTTO MD PA
Entity Type:Organization
Organization Name:R OTTO MD PA
Other - Org Name:NORTH TEXAS ENT & ALLERGY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:JON
Authorized Official - Last Name:OTTO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:940-891-6100
Mailing Address - Street 1:1209 BENT OAKS CT
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76210-3300
Mailing Address - Country:US
Mailing Address - Phone:940-891-6100
Mailing Address - Fax:940-891-6110
Practice Address - Street 1:1209 BENT OAKS CT
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76210-3300
Practice Address - Country:US
Practice Address - Phone:940-891-6100
Practice Address - Fax:940-891-6110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-15
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK6206207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX176784001Medicaid
TXF94766Medicare UPIN
TX00588ZMedicare PIN