Provider Demographics
NPI:1699729608
Name:OTTO, LESLEY NICOLOFF (MD)
Entity type:Individual
Prefix:
First Name:LESLEY
Middle Name:NICOLOFF
Last Name:OTTO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LESLEY
Other - Middle Name:N
Other - Last Name:OTTO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:847 NE19TH
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232
Mailing Address - Country:US
Mailing Address - Phone:503-963-2801
Mailing Address - Fax:503-963-2825
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:97225-6625
Practice Address - Country:US
Practice Address - Phone:503-297-4123
Practice Address - Fax:509-297-0344
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60636494207VG0400X, 207VF0040X
ORMD18878207VF0040X, 207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyUrogynecology and Reconstructive Pelvic Surgery
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR073122Medicaid
ORMD18878OtherLICENSE
WA2038459Medicaid
WA1699729608Medicaid
OR931237109OtherTAX ID
WA2038459Medicaid
OR073122Medicaid
OR175086Medicare PIN
ORR132842Medicare PIN