Provider Demographics
NPI:1639129380
Name:OTTEN, STACIE MICHELLE (MD)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:MICHELLE
Last Name:OTTEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2619 DEERFOOT TRL
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-2715
Mailing Address - Country:US
Mailing Address - Phone:512-633-4028
Mailing Address - Fax:
Practice Address - Street 1:1201 W 38TH ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1006
Practice Address - Country:US
Practice Address - Phone:512-324-1010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK5171207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX118398003Medicaid
TX118398009Medicaid
TX118398006Medicaid
TX118398001Medicaid
TX118398007Medicaid
TX118398012Medicaid
TX118398007Medicaid
TX118398006Medicaid
TX118398012Medicaid
TX118398003Medicaid
TX118398001Medicaid
TX8F2742Medicare PIN
TX8404K9Medicare PIN
TX86978JMedicare PIN