Basic Information
| Provider Information | |||||||||
| NPI: | 1912978115 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OTTEMOELLER | ||||||||
| FirstName: | LINDA | ||||||||
| MiddleName: | GRACE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 315 MERCY AVE | ||||||||
| Address2: | STE 400 | ||||||||
| City: | MERCED | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095643700 | ||||||||
| FaxNumber: | 2095643725 | ||||||||
| Practice Location | |||||||||
| Address1: | 315 MERCY AVE | ||||||||
| Address2: | STE 400 | ||||||||
| City: | MERCED | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095643700 | ||||||||
| FaxNumber: | 2095643725 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2006 | ||||||||
| LastUpdateDate: | 03/23/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X | G67412 | CA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 00G674120 | 05 | CA | MEDICAID |