Provider Demographics
NPI:1932173051
Name:OTTO, RUSSELL JON (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:JON
Last Name:OTTO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:1209 BENT OAKS CT
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76210-3300
Mailing Address - Country:US
Mailing Address - Phone:940-891-6100
Mailing Address - Fax:940-891-6110
Practice Address - Street 1:1209 BENT OAKS CT
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76210-3300
Practice Address - Country:US
Practice Address - Phone:940-891-6100
Practice Address - Fax:940-891-6110
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK6206207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX037103102Medicaid
TX8F1281Medicare PIN
F94766Medicare UPIN