Provider Demographics
NPI:1720261563
Name:OTTERBURN, DAVID MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:MARK
Last Name:OTTERBURN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:560 1ST AVE # TCH169
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-6402
Mailing Address - Country:US
Mailing Address - Phone:212-263-8279
Mailing Address - Fax:212-263-3279
Practice Address - Street 1:560 1ST AVE # TCH169
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6402
Practice Address - Country:US
Practice Address - Phone:212-263-8279
Practice Address - Fax:212-263-3279
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-16
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA59579208200000X, 208600000X
NY257612208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA511I020163Medicare PIN