Provider Demographics
NPI:1972502128
Name:OTTO, DESIREE L (MD)
Entity Type:Individual
Prefix:
First Name:DESIREE
Middle Name:L
Last Name:OTTO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1231 116TH AVE NE
Mailing Address - Street 2:SUITE 950
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-3804
Mailing Address - Country:US
Mailing Address - Phone:425-454-3366
Mailing Address - Fax:425-943-3201
Practice Address - Street 1:1231 116TH AVE NE
Practice Address - Street 2:SUITE 950
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3804
Practice Address - Country:US
Practice Address - Phone:425-454-3366
Practice Address - Fax:425-943-3201
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2015-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00039027207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8278772Medicaid
WAH46940Medicare UPIN
WA8278772Medicaid