Provider Demographics
NPI:1942313226
Name:OTANI, ROBERT KELLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:KELLEY
Last Name:OTANI
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 8127
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95927-8127
Mailing Address - Country:US
Mailing Address - Phone:530-343-8438
Mailing Address - Fax:530-343-2609
Practice Address - Street 1:552 VALLOMBROSA AVE
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-4038
Practice Address - Country:US
Practice Address - Phone:530-343-8438
Practice Address - Fax:530-343-2609
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG55038208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA02259477OtherDEA
CAA52850Medicare UPIN
CA00G550380Medicare ID - Type Unspecified