Provider Demographics
NPI:1578586939
Name:OTTO, GENE P III (MD)
Entity Type:Individual
Prefix:DR
First Name:GENE
Middle Name:P
Last Name:OTTO
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1570 CORNWALL RD
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17042-7403
Mailing Address - Country:US
Mailing Address - Phone:717-273-4681
Mailing Address - Fax:717-273-0946
Practice Address - Street 1:1570 CORNWALL RD
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-7403
Practice Address - Country:US
Practice Address - Phone:717-273-4681
Practice Address - Fax:717-273-0946
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD020344E208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0007158610003Medicaid
C29817Medicare UPIN