Provider Demographics
NPI:1154565273
Name:OTTO, SAMUEL JAMES (MD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:JAMES
Last Name:OTTO
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 1:2376 N 400 E
Mailing Address - Street 2:STE A104
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074-3413
Mailing Address - Country:US
Mailing Address - Phone:435-882-0071
Mailing Address - Fax:435-882-0073
Practice Address - Street 1:2424 S 90TH ST
Practice Address - Street 2:SUITE 408
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53227-2455
Practice Address - Country:US
Practice Address - Phone:414-385-2716
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-21
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7223921-1205208800000X
WI19702208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1154565273Medicaid
UT1154565273Medicaid
UT1154565273Medicaid
P00759609Medicare PIN