Provider Demographics
NPI:1841494689
Name:OTTO, RANDALL JASON (MD)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:JASON
Last Name:OTTO
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 1:1008 S SPRING AVE FL 1
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-2520
Mailing Address - Country:US
Mailing Address - Phone:314-977-5350
Mailing Address - Fax:314-977-1629
Practice Address - Street 1:1011 BOWLES AVE STE 400
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-2387
Practice Address - Country:US
Practice Address - Phone:314-977-7200
Practice Address - Fax:636-326-6533
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012011162207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO136637OtherHEALTHCARE USA
MO4258558OtherCIGNA
MO501357701Medicaid
MO122950063OtherMEDICARE PTAN
MOA82171OtherHEALTHLINK
MO771091OtherANTHEM BLUE CROSS BLUE SHIELD