Provider Demographics
NPI:1295965176
Name:OTTO, IAN SETH
Entity type:Individual
Prefix:MR
First Name:IAN
Middle Name:SETH
Last Name:OTTO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13525 VALBUENA CT
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-3087
Mailing Address - Country:US
Mailing Address - Phone:904-536-4962
Mailing Address - Fax:
Practice Address - Street 1:13400 SUTTON PARK DR S
Practice Address - Street 2:SUITE 1101
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-0236
Practice Address - Country:US
Practice Address - Phone:904-254-8713
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-25
Last Update Date:2009-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL26-4600206235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist