Provider Demographics
NPI:1922036151
Name:OTTO, ROBERT JAY (AUD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:JAY
Last Name:OTTO
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9485 MENTOR AVE
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-8723
Mailing Address - Country:US
Mailing Address - Phone:440-255-1800
Mailing Address - Fax:440-255-2088
Practice Address - Street 1:9485 MENTOR AVE
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-4597
Practice Address - Country:US
Practice Address - Phone:440-255-1800
Practice Address - Fax:440-255-2088
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHA-01292231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2531077Medicaid
OH2531077Medicaid
OHA-01292Medicare UPIN