Provider Demographics
NPI:1851336325
Name:OTTO, ANDREA SHAE (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:SHAE
Last Name:OTTO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:ANDREA
Other - Middle Name:SHAE
Other - Last Name:HEROLD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1001 S KIRKWOOD RD
Mailing Address - Street 2:STE 300
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63122-7254
Mailing Address - Country:US
Mailing Address - Phone:314-543-5943
Mailing Address - Fax:314-543-5953
Practice Address - Street 1:1001 S KIRKWOOD RD
Practice Address - Street 2:STE 300
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63122-7254
Practice Address - Country:US
Practice Address - Phone:314-543-5943
Practice Address - Fax:314-543-5953
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE23567207Q00000X
MO2012013484207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE23567OtherSTATE LICENSE NUMBER
MO2012013484OtherSTATE LICENSE