Provider Demographics
NPI:1316950884
Name:OTTI, THEODORE IKECHUKWU (MD)
Entity type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:IKECHUKWU
Last Name:OTTI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 4031
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63006-4031
Mailing Address - Country:US
Mailing Address - Phone:314-577-5778
Mailing Address - Fax:636-939-1629
Practice Address - Street 1:1035 BELLEVUE AVE STE 315
Practice Address - Street 2:
Practice Address - City:RICHMOND HEIGHTS
Practice Address - State:MO
Practice Address - Zip Code:63117-1856
Practice Address - Country:US
Practice Address - Phone:314-683-6110
Practice Address - Fax:314-485-2136
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO103005207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208601823Medicaid
000094249Medicare ID - Type Unspecified
MO208601823Medicaid