Provider Demographics
NPI:1952308140
Name:OTTINGER, C. JOE (MD)
Entity Type:Individual
Prefix:
First Name:C.
Middle Name:JOE
Last Name:OTTINGER
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 1:7956 W JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-4140
Mailing Address - Country:US
Mailing Address - Phone:260-436-2416
Mailing Address - Fax:260-436-9662
Practice Address - Street 1:7956 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4140
Practice Address - Country:US
Practice Address - Phone:260-436-2416
Practice Address - Fax:260-436-9662
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2014-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01023383A2084N0400X, 2084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100096120Medicaid
MI2717847Medicaid
IN130005977OtherRR MEDICARE
OH0295872Medicaid
MI2717847Medicaid
IN130005977Medicare PIN
IN130005977OtherRR MEDICARE
B28464Medicare UPIN
OH0295872Medicaid
668120EMedicare PIN