Provider Demographics
NPI:1508328329
Name:OTTERSON, SARAH ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:ELIZABETH
Last Name:OTTERSON
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 1:9830 MARIPOSA LN APT 208
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-5606
Mailing Address - Country:US
Mailing Address - Phone:614-570-6479
Mailing Address - Fax:
Practice Address - Street 1:8701 WATERTOWN PLANK ROAD
Practice Address - Street 2:GRADUATE MEDICAL EDUCATION
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226
Practice Address - Country:US
Practice Address - Phone:414-955-0717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-01
Last Update Date:2024-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI83874-202084N0402X
NM390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child NeurologyGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program