Provider Demographics
NPI:1831184266
Name:TEIXEIRA, OTTO HP (MD)
Entity type:Individual
Prefix:DR
First Name:OTTO
Middle Name:HP
Last Name:TEIXEIRA
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:PO BOX 699
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:TN
Mailing Address - Zip Code:37684-0699
Mailing Address - Country:US
Mailing Address - Phone:423-439-7320
Mailing Address - Fax:423-439-7343
Practice Address - Street 1:325 N STATE OF FRANKLIN RD., GROUND FLOOR
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6062
Practice Address - Country:US
Practice Address - Phone:423-439-7320
Practice Address - Fax:423-439-7343
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN34692208000000X
TN0346922080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3714470OtherGROUP MEDICARE #
TN3714470OtherGROUP MEDICARE #