Basic Information
| Provider Information | |||||||||
| NPI: | 1184719445 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OTTO | ||||||||
| FirstName: | DEAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12265 TOWNSEND ROAD | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2158561010 | ||||||||
| FaxNumber: | 2156983730 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 MEDICAL CAMPUS DR | ||||||||
| Address2: | |||||||||
| City: | LANSDALE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194461259 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2153614440 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 08/25/2016 | ||||||||
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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 | 207P00000X | MD058541-L | PA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 960306 | 01 | ABEM | OTHER | BO4369890 | 01 | PA | DEA | OTHER | MD058541-L | 01 | PA | STATE LICENSE | OTHER |