Provider Demographics
NPI:1609812460
Name:OTIS, MICHAEL V (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:V
Last Name:OTIS
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 1:1225 E WEISGARBER RD
Mailing Address - Street 2:STE 200
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37909-2604
Mailing Address - Country:US
Mailing Address - Phone:865-584-4747
Mailing Address - Fax:
Practice Address - Street 1:7211 WELLINGTON DR
Practice Address - Street 2:STE 201
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37919-5968
Practice Address - Country:US
Practice Address - Phone:865-584-5762
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN06684207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN080064819OtherRR MEDICARE PIN
TN3173794Medicaid
B03618Medicare UPIN
TN3173792Medicare ID - Type UnspecifiedLEGACY PIN
TN3173794Medicaid