Provider Demographics
NPI:1063732840
Name:OTTO, CANDACE (LMT)
Entity type:Individual
Prefix:
First Name:CANDACE
Middle Name:
Last Name:OTTO
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5301 WESTBARD CIR
Mailing Address - Street 2:225
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20816-1401
Mailing Address - Country:US
Mailing Address - Phone:301-907-0153
Mailing Address - Fax:301-907-0153
Practice Address - Street 1:5301 WESTBARD CIR
Practice Address - Street 2:225
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20816-1401
Practice Address - Country:US
Practice Address - Phone:301-907-0153
Practice Address - Fax:301-907-0153
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-03
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDM02618171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD12099942OtherCOUNCIL FOR AFFORDABLE QUALITY HEALTHCARE (CAQH)