Provider Demographics
NPI:1639133747
Name:STALLWORTH, OTTO EVANS (MD)
Entity type:Individual
Prefix:DR
First Name:OTTO
Middle Name:EVANS
Last Name:STALLWORTH
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 1:210 N TUSTIN AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3807
Mailing Address - Country:US
Mailing Address - Phone:800-883-7243
Mailing Address - Fax:714-647-1245
Practice Address - Street 1:4500 W 116TH ST
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-2209
Practice Address - Country:US
Practice Address - Phone:800-883-7243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2007-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC33769207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C337690Medicaid
CA00C337690Medicaid
CAC33769Medicare PIN