Provider Demographics
NPI:1588662290
Name:OTEY, THEODORE (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:OTEY
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 1:4306 S MACGREGOR WAY
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77021-1611
Mailing Address - Country:US
Mailing Address - Phone:713-748-7086
Mailing Address - Fax:
Practice Address - Street 1:4003 GRIGGS RD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77021-1447
Practice Address - Country:US
Practice Address - Phone:713-748-7086
Practice Address - Fax:713-748-3814
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ1343207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX136460603Medicaid
TX00211LMedicare ID - Type Unspecified
TX136460603Medicaid