Provider Demographics
NPI:1558324590
Name:OTTO, MICHAEL E (RPT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:E
Last Name:OTTO
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1951 BENCH RD
Mailing Address - Street 2:SUITE E
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-2073
Mailing Address - Country:US
Mailing Address - Phone:208-237-2080
Mailing Address - Fax:208-237-1084
Practice Address - Street 1:1951 BENCH RD
Practice Address - Street 2:SUITE E
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2073
Practice Address - Country:US
Practice Address - Phone:208-237-2080
Practice Address - Fax:208-237-1084
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2013-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDRPT186225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002682600Medicaid
ID000010020633OtherGCPT REGENCE OF ID
IDT1385OtherGCPT BLUE CROSS OF ID
ID1650716Medicare ID - Type UnspecifiedGATE CITY
ID002682600Medicaid
ID000010020633OtherGCPT REGENCE OF ID