Provider Demographics
NPI:1821381674
Name:OTERO, JESSE ERNEST (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:ERNEST
Last Name:OTERO
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4601 PARK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-2290
Mailing Address - Country:US
Mailing Address - Phone:704-323-2237
Mailing Address - Fax:
Practice Address - Street 1:2001 VAIL AVE STE 200
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1222
Practice Address - Country:US
Practice Address - Phone:704-323-2564
Practice Address - Fax:704-323-3792
Is Sole Proprietor?:No
Enumeration Date:2011-05-25
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2016-00057207X00000X, 207X00000X
IAMD-43916207XS0114X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1821381674Medicaid
SCNC2694Medicaid
NC0397730024Medicare NSC
NCNCS332AMedicare PIN