Provider Demographics
NPI:1821004144
Name:OTT, RICHARD ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:ALAN
Last Name:OTT
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 9036
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92658-1036
Mailing Address - Country:US
Mailing Address - Phone:714-774-1102
Mailing Address - Fax:949-459-0100
Practice Address - Street 1:1211 W LA PALMA AVE STE 608
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-2813
Practice Address - Country:US
Practice Address - Phone:714-774-1102
Practice Address - Fax:949-459-0100
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2022-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG45864208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA04242007489190OtherNPI - GROUP
CAGR0095360OtherCAL-OPTIMA DIRECT (GROUP)
CAGR0095360Medicaid
CAOOG458641N87OtherCAL-OPTIMADIRECT-PERSONAL
CAGR0095360Medicaid
CAOOG458640Medicaid
CAOOG458641N87OtherCAL-OPTIMADIRECT-PERSONAL
CAGR0095360Medicaid
CAW16477Medicare ID - Type UnspecifiedFORMER GROUP MEDICARE ID
CAOOG458640Medicaid