Provider Demographics
NPI:1295303436
Name:OTTESEN, TYLER (DC)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:OTTESEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 ROUTE 17K STE 203
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12550-3920
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:52 ROUTE 17K STE 203
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:NY
Practice Address - Zip Code:12550-3920
Practice Address - Country:US
Practice Address - Phone:845-565-5410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-15
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX013461-01111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor