Provider Demographics
NPI:1841226487
Name:OTIS, STEPHANIE A (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:A
Last Name:OTIS
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:12639 OLD TESSON RD
Mailing Address - Street 2:SUITE 115
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2786
Mailing Address - Country:US
Mailing Address - Phone:314-849-0311
Mailing Address - Fax:314-849-4423
Practice Address - Street 1:621 S NEW BALLAS RD
Practice Address - Street 2:SUITE 63B
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8232
Practice Address - Country:US
Practice Address - Phone:314-983-4700
Practice Address - Fax:314-692-9862
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2013-08-28
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Provider Licenses
StateLicense IDTaxonomies
MO106730207X00000X, 207XP3100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XP3100XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryPediatric Orthopaedic Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO0900169OtherUNITED HEALTHCARE
MO256445OtherHEALTHLINK
MO207688508Medicaid
MO83380V3223OtherGROUP HEALTHPLAN
MO200030003OtherRAILROAD MEDICARE
MO4534390OtherAETNA
MO1598506001OtherCIGNA
MO24774OtherBLUE CROSS BLUE SHIELD
MO200030003OtherRAILROAD MEDICARE
MO042012295Medicare PIN