Provider Demographics
NPI:1851719553
Name:OTTO, MIRA (MD)
Entity Type:Individual
Prefix:
First Name:MIRA
Middle Name:
Last Name:OTTO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MIRA
Other - Middle Name:
Other - Last Name:SAMET
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2799 W GRAND BLVD
Mailing Address - Street 2:HENRY FORD HOSPITAL, MEDICAL EDUCATION DEPARTMENT
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-2608
Mailing Address - Country:US
Mailing Address - Phone:313-916-2600
Mailing Address - Fax:
Practice Address - Street 1:5500 AUTO CLUB DR STE 300
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-2779
Practice Address - Country:US
Practice Address - Phone:313-982-8214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-01
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301105094207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program