Provider Demographics
NPI:1891865705
Name:OTTENBACHER, JOHN C (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:C
Last Name:OTTENBACHER
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:PO BOX 157
Mailing Address - Street 2:
Mailing Address - City:SELBY
Mailing Address - State:SD
Mailing Address - Zip Code:57472-0157
Mailing Address - Country:US
Mailing Address - Phone:605-649-7366
Mailing Address - Fax:
Practice Address - Street 1:8001 WEST 5TH STREET
Practice Address - Street 2:
Practice Address - City:BOWDLE
Practice Address - State:SD
Practice Address - Zip Code:57428
Practice Address - Country:US
Practice Address - Phone:605-285-9832
Practice Address - Fax:605-285-6986
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1128207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9174905OtherDAKOTACARE
SD5604543Medicaid
SD7684OtherWELLMARK BC/BS OF SD
SD9174905OtherDAKOTACARE
SD5604543Medicaid
SDP00092890Medicare PIN