Provider Demographics
NPI:1629075429
Name:OTHERSEN, VICTORIA ANN (DO)
Entity Type:Individual
Prefix:DR
First Name:VICTORIA
Middle Name:ANN
Last Name:OTHERSEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:VICTONIA
Other - Middle Name:ANN
Other - Last Name:PIEKARSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:362 MERIDIAN PARKE LN STE A
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-9425
Practice Address - Country:US
Practice Address - Phone:317-528-8760
Practice Address - Fax:317-528-8761
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-007433207Q00000X
IN02004084A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000522568OtherANTHEM
IN200250180AMedicaid
OHKA4129752Medicare PIN
H78612Medicare UPIN