Provider Demographics
NPI:1205997244
Name:OTERO, SUSAN E (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:E
Last Name:OTERO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:EARLY
Other - Last Name:OTERO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:3746 FOOTHILL BLVD STE B140
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91214-1740
Mailing Address - Country:US
Mailing Address - Phone:310-445-5999
Mailing Address - Fax:
Practice Address - Street 1:251 LITTLE FALLS DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19808-1674
Practice Address - Country:US
Practice Address - Phone:310-445-5999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD14270208200000X
DEC1-0025325208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD528271300Medicaid
DC25544400Medicaid
DC122538S79Medicare PIN
DC25544400Medicaid