Provider Demographics
NPI:1891318127
Name:OTA, RIICHI ANDRE (MD)
Entity Type:Individual
Prefix:
First Name:RIICHI
Middle Name:ANDRE
Last Name:OTA
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 1:6071 W. OUTER DRIVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235
Mailing Address - Country:US
Mailing Address - Phone:313-966-3300
Mailing Address - Fax:
Practice Address - Street 1:6071 W. OUTER DRIVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235
Practice Address - Country:US
Practice Address - Phone:313-966-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-21
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program