Provider Demographics
NPI:1588671721
Name:OTERO, JON C (PT, ATC)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:C
Last Name:OTERO
Suffix:
Gender:M
Credentials:PT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:BELEN
Mailing Address - State:NM
Mailing Address - Zip Code:87002-3606
Mailing Address - Country:US
Mailing Address - Phone:505-317-7773
Mailing Address - Fax:855-844-8611
Practice Address - Street 1:101 N 6TH ST
Practice Address - Street 2:
Practice Address - City:BELEN
Practice Address - State:NM
Practice Address - Zip Code:87002-3605
Practice Address - Country:US
Practice Address - Phone:505-710-8536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3063225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM5239Medicaid