Provider Demographics
NPI:1710920111
Name:OTT, DEREK A (MD)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:A
Last Name:OTT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8306 WILSHIRE BLVD
Mailing Address - Street 2:#501
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-2382
Mailing Address - Country:US
Mailing Address - Phone:310-613-2414
Mailing Address - Fax:805-494-8379
Practice Address - Street 1:10850 WILSHIRE BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024
Practice Address - Country:US
Practice Address - Phone:310-470-2033
Practice Address - Fax:310-394-3769
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA616012084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A616011Medicaid
CAP00166475OtherRAILROAD MEDICARE
CAG64595Medicare UPIN
CAA61601AMedicare ID - Type UnspecifiedMEDICARE PROVIDER