Provider Demographics
NPI:1811703663
Name:OTTERBACHER, CONRAD MAXIMILLIAN
Entity type:Individual
Prefix:
First Name:CONRAD
Middle Name:MAXIMILLIAN
Last Name:OTTERBACHER
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 1:21 PAISLEY GRN
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46385-9277
Mailing Address - Country:US
Mailing Address - Phone:219-241-9940
Mailing Address - Fax:
Practice Address - Street 1:21 PAISLEY GRN
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46385-9277
Practice Address - Country:US
Practice Address - Phone:219-241-9940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-06
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program