Provider Demographics
NPI:1720172109
Name:OTERO, STEPHEN J (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:J
Last Name:OTERO
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 26666
Mailing Address - Street 2:PHS PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-5356
Mailing Address - Fax:505-923-5354
Practice Address - Street 1:129 EL PASO ROAD
Practice Address - Street 2:LCMC WHITE MOUNTAIN MEDICAL ASSOCIATES
Practice Address - City:RUIDOSO
Practice Address - State:NM
Practice Address - Zip Code:88345
Practice Address - Country:US
Practice Address - Phone:575-630-8350
Practice Address - Fax:575-257-4055
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2008-08-15
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Provider Licenses
StateLicense IDTaxonomies
NMMD2003-0049207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM17351235Medicaid
NM17351235Medicaid
I02420Medicare UPIN