Basic Information
| Provider Information | |||||||||
| NPI: | 1053576603 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OTSUKA | ||||||||
| FirstName: | RYOHEI | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 163 BUTNER DR | ||||||||
| Address2: | |||||||||
| City: | HOPE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472469447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8125466000 | ||||||||
| FaxNumber: | 8125460368 | ||||||||
| Practice Location | |||||||||
| Address1: | 163 BUTNER DR | ||||||||
| Address2: | |||||||||
| City: | HOPE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472469447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8125466000 | ||||||||
| FaxNumber: | 8125460368 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2008 | ||||||||
| LastUpdateDate: | 11/28/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01070005A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 201085580 | 05 | IN | MEDICAID |