Provider Demographics
NPI:1831206903
Name:OTTO, DAVID HARDISON (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:HARDISON
Last Name:OTTO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:309 W 106TH ST
Mailing Address - Street 2:APT 1C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-3484
Mailing Address - Country:US
Mailing Address - Phone:917-647-9828
Mailing Address - Fax:718-784-0240
Practice Address - Street 1:49 HOOPER ST
Practice Address - Street 2:
Practice Address - City:WISCASSET
Practice Address - State:ME
Practice Address - Zip Code:04578-4053
Practice Address - Country:US
Practice Address - Phone:207-882-7911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY228128207R00000X
MEMD26136207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine