Provider Demographics
NPI:1265166821
Name:YESPICA OTAOLA, ENRIQUE ANDRES (MD)
Entity type:Individual
Prefix:DR
First Name:ENRIQUE
Middle Name:ANDRES
Last Name:YESPICA OTAOLA
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 1:1465 S GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-1003
Mailing Address - Country:US
Mailing Address - Phone:314-577-5634
Mailing Address - Fax:314-268-4019
Practice Address - Street 1:1465 S GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1003
Practice Address - Country:US
Practice Address - Phone:314-577-5634
Practice Address - Fax:314-268-4019
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-11
Last Update Date:2025-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022019664390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program