Provider Demographics
NPI:1215963509
Name:OTIS, PATRICIA SUE (MD)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:SUE
Last Name:OTIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1049 EDGEWATER ST NW STE 150
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97304-4046
Mailing Address - Country:US
Mailing Address - Phone:503-814-4400
Mailing Address - Fax:503-814-4414
Practice Address - Street 1:1049 EDGEWATER ST NW # 150
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97304-4046
Practice Address - Country:US
Practice Address - Phone:503-814-4400
Practice Address - Fax:503-814-4414
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE23396207Q00000X
ORMD27752207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR278841Medicaid
ORP000635156OtherOREGON RAILROAD PROVIDER NUMBER
ORR138862OtherMEDICARE PROVIDER NUMBER