Provider Demographics
NPI:1982613709
Name:OTT, CARL
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:
Last Name:OTT
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 1:525 LILLY RD NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5101
Mailing Address - Country:US
Mailing Address - Phone:360-493-4002
Mailing Address - Fax:360-493-5524
Practice Address - Street 1:525 LILLY RD NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5101
Practice Address - Country:US
Practice Address - Phone:360-493-7230
Practice Address - Fax:360-493-4180
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA21917207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMD00021917OtherSTATE LICENSE
WA1982613709Medicaid
WAMD00021917OtherSTATE LICENSE