Provider Demographics
NPI:1093704827
Name:OTAH, KENNETH ESE SR (MD MSC FACC)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ESE
Last Name:OTAH
Suffix:SR
Gender:
Credentials:MD MSC FACC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 ELDRIDGE RD
Mailing Address - Street 2:SUITE E
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77478-4083
Mailing Address - Country:US
Mailing Address - Phone:281-232-3886
Mailing Address - Fax:281-232-3986
Practice Address - Street 1:138 ELDRIDGE RD
Practice Address - Street 2:SUITE E
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77478-4083
Practice Address - Country:US
Practice Address - Phone:281-232-3886
Practice Address - Fax:281-232-3986
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL7835207RC0000X, 207RI0001X, 207RI0011X
HIMD-25039207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical & Laboratory Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1754541Medicaid
TX1754541Medicaid
8D3611Medicare PIN