Provider Demographics
NPI:1417138769
Name:LESLEY NICOLOFF OTTO MD, LLC
Entity type:Organization
Organization Name:LESLEY NICOLOFF OTTO MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:LESLEY
Authorized Official - Middle Name:N
Authorized Official - Last Name:OTTO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-297-4123
Mailing Address - Street 1:9155 SW BARNES RD
Mailing Address - Street 2:SUITE 634
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-6633
Mailing Address - Country:US
Mailing Address - Phone:503-297-4123
Mailing Address - Fax:503-297-0344
Practice Address - Street 1:9155 SW BARNES RD
Practice Address - Street 2:SUITE 634
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6633
Practice Address - Country:US
Practice Address - Phone:503-297-4123
Practice Address - Fax:503-297-0344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-15
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD18878207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR073122Medicaid
ORMD18878OtherMEDICAL LICENSE
ORR132843Medicare PIN
ORG50660Medicare UPIN