Basic Information
| Provider Information | |||||||||
| NPI: | 1417138769 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LESLEY NICOLOFF OTTO MD, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9155 SW BARNES RD | ||||||||
| Address2: | SUITE 634 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972256633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032974123 | ||||||||
| FaxNumber: | 5032970344 | ||||||||
| Practice Location | |||||||||
| Address1: | 9155 SW BARNES RD | ||||||||
| Address2: | SUITE 634 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972256633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032974123 | ||||||||
| FaxNumber: | 5032970344 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2007 | ||||||||
| LastUpdateDate: | 12/20/2010 | ||||||||
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| AuthorizedOfficialLastName: | OTTO | ||||||||
| AuthorizedOfficialFirstName: | LESLEY | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 5032974123 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X | MD18878 | OR | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 073122 | 05 | OR | MEDICAID | MD18878 | 01 | OR | MEDICAL LICENSE | OTHER |