Provider Demographics
NPI:1588776884
Name:OTERO, WILLIAM ENRIQUE (MD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:ENRIQUE
Last Name:OTERO
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 1:4911 W FULLERTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60639-2505
Mailing Address - Country:US
Mailing Address - Phone:773-772-4900
Mailing Address - Fax:773-772-0298
Practice Address - Street 1:2363 N CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-2939
Practice Address - Country:US
Practice Address - Phone:773-772-4900
Practice Address - Fax:773-772-0298
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036 102552207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036102552Medicaid
IL01626950OtherBLUE CROSS BLUE SHIELD
IL36 4385201OtherTAX IDENTIFICATION NUMBER