Provider Demographics
NPI:1083671705
Name:OTTO, CHRISTOPHER ANDREW (PT)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:ANDREW
Last Name:OTTO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 N 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:SHELDON
Mailing Address - State:IA
Mailing Address - Zip Code:51201-1235
Mailing Address - Country:US
Mailing Address - Phone:712-324-5041
Mailing Address - Fax:712-324-6025
Practice Address - Street 1:118 N 7TH AVE
Practice Address - Street 2:
Practice Address - City:SHELDON
Practice Address - State:IA
Practice Address - Zip Code:51201-1235
Practice Address - Country:US
Practice Address - Phone:712-324-5041
Practice Address - Fax:712-324-6025
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA03328225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0601260Medicaid
IA0803635Medicaid
IA0655407Medicaid
IA16E263Medicare ID - Type UnspecifiedSR. CARE MEDICARE #
IA0803635Medicaid
IA16U126Medicare Oscar/Certification
IA0655407Medicaid
IA0601260Medicaid