Provider Demographics
NPI:1821007378
Name:OTT, CAROL (MD)
Entity Type:Individual
Prefix:DR
First Name:CAROL
Middle Name:
Last Name:OTT
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 1:1900 S. BROAD ST
Mailing Address - Street 2:2ND FLR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19145
Mailing Address - Country:US
Mailing Address - Phone:215-476-5870
Mailing Address - Fax:215-476-5873
Practice Address - Street 1:1900 S. BROAD ST
Practice Address - Street 2:2ND FLR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19145
Practice Address - Country:US
Practice Address - Phone:215-476-5870
Practice Address - Fax:215-476-5873
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-014156-E208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAE79127Medicare UPIN
PA174830Medicare ID - Type Unspecified