Provider Demographics
NPI:1639361967
Name:OTT, MONICA L (MD)
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:L
Last Name:OTT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MONICA
Other - Middle Name:L
Other - Last Name:TEGELER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:STE 130 - PROVIDER ENROLLMENT
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1633 N CAPITOL AVE
Practice Address - Street 2:STE 322
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1476
Practice Address - Country:US
Practice Address - Phone:317-962-2929
Practice Address - Fax:317-962-2070
Is Sole Proprietor?:No
Enumeration Date:2007-08-10
Last Update Date:2018-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01067231A207Q00000X, 207QG0300X
TNMD 41929207Q00000X
MO2008028219207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200955220Medicaid
INP00831852OtherRR MEDICARE
IN200955220Medicaid
INP01294248Medicare PIN
IN715530EFFFMedicare PIN
IN188920XMedicare PIN