Provider Demographics
NPI:1528059078
Name:OTTEMAN, LARRY A (MD)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:A
Last Name:OTTEMAN
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 1:1111 DUFF AVE
Mailing Address - Street 2:
Mailing Address - City:AMES
Mailing Address - State:IA
Mailing Address - Zip Code:50010-3014
Mailing Address - Country:US
Mailing Address - Phone:515-239-4401
Mailing Address - Fax:515-239-4791
Practice Address - Street 1:1111 DUFF AVE
Practice Address - Street 2:
Practice Address - City:AMES
Practice Address - State:IA
Practice Address - Zip Code:50010-3014
Practice Address - Country:US
Practice Address - Phone:515-239-4401
Practice Address - Fax:515-239-4791
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2012-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA24794207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0031609Medicaid
IA22843Medicare ID - Type Unspecified
IA0031609Medicaid