Provider Demographics
NPI:1629086491
Name:OTTO, BETTRICIA A (DPM)
Entity Type:Individual
Prefix:
First Name:BETTRICIA
Middle Name:A
Last Name:OTTO
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3181 SW SAM JACKSON PARK RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239
Mailing Address - Country:US
Mailing Address - Phone:503-494-6616
Mailing Address - Fax:503-346-6846
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3011
Practice Address - Country:US
Practice Address - Phone:503-494-6616
Practice Address - Fax:503-346-6846
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI914213E00000X
ORDP155874213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist