Provider Demographics
NPI:1710988647
Name:OTTO, RONALD J (MD)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:J
Last Name:OTTO
Suffix:
Gender:M
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:PO BOX 15648
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95852-0648
Mailing Address - Country:US
Mailing Address - Phone:951-781-2270
Mailing Address - Fax:951-781-2293
Practice Address - Street 1:4445 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-4135
Practice Address - Country:US
Practice Address - Phone:951-788-3400
Practice Address - Fax:951-788-3194
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG515112085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G515110Medicaid
CA009515110Medicaid
CA00G515110Medicare PIN
CA00G515110Medicaid
CA00G515114Medicare PIN
CA00G515113Medicare PIN
A52010Medicare UPIN
CA009515110Medicaid
CA00G515111Medicare PIN