Provider Demographics
NPI:1558361972
Name:OTSUJI, GARY G (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:G
Last Name:OTSUJI
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 1:15990 W 9 MILE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-4826
Mailing Address - Country:US
Mailing Address - Phone:248-849-4226
Mailing Address - Fax:248-849-4240
Practice Address - Street 1:22250 PROVIDENCE DR
Practice Address - Street 2:5TH FLOOR
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4825
Practice Address - Country:US
Practice Address - Phone:248-849-3441
Practice Address - Fax:248-849-5389
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301036749207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI176548310Medicaid
MI0F3602006Medicare ID - Type Unspecified
MID72588Medicare UPIN