Provider Demographics
NPI:1124054101
Name:OTT, BRIAN R (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:R
Last Name:OTT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 HOPPIN ST
Mailing Address - Street 2:SUITE 318
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4141
Mailing Address - Country:US
Mailing Address - Phone:401-793-8382
Mailing Address - Fax:401-793-8312
Practice Address - Street 1:593 EDDY ST
Practice Address - Street 2:APC 6
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4923
Practice Address - Country:US
Practice Address - Phone:401-444-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD05819207R00000X, 207RG0300X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9006551Medicaid
RI00-7058024Medicare ID - Type Unspecified
RIA57661Medicare UPIN