Provider Demographics
NPI:1558463505
Name:OTT, TIMOTHY TITUS (DO)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:TITUS
Last Name:OTT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 N 11TH ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-2662
Mailing Address - Country:US
Mailing Address - Phone:217-224-9484
Mailing Address - Fax:217-224-7950
Practice Address - Street 1:612 N 11TH ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-2662
Practice Address - Country:US
Practice Address - Phone:217-224-9484
Practice Address - Fax:217-224-7950
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS006379L207Q00000X
IL036-126471207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001263196 0001Medicaid
IL036126471Medicaid
PA575684Medicare PIN
IL256510055Medicare PIN
PAE59456Medicare UPIN
IL036126471Medicaid