Basic Information
| Provider Information | |||||||||
| NPI: | 1013080878 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OTT | ||||||||
| FirstName: | ANITA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5030 STATE ROAD | ||||||||
| Address2: | SUITE 2-400 | ||||||||
| City: | DREXEL HILL | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6103941365 | ||||||||
| FaxNumber: | 6103941368 | ||||||||
| Practice Location | |||||||||
| Address1: | 5030 STATE ROAD | ||||||||
| Address2: | SUITE 2-400 | ||||||||
| City: | DREXEL HILL | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190264605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6103941365 | ||||||||
| FaxNumber: | 6103941368 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2006 | ||||||||
| LastUpdateDate: | 04/22/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OS008470L | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 001856710 | 05 | PA | MEDICAID |