Basic Information
Provider Information
NPI: 1346467693
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: OTTO
FirstName: NICHOLAS
MiddleName: P.
NamePrefix: DR.
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 629 D LOWTHER ROAD
Address2:  
City: LEWISBERRY
State: PA
PostalCode: 173399527
CountryCode: US
TelephoneNumber: 7179325200
FaxNumber: 7179323095
Practice Location
Address1: 629 D LOWTHER ROAD
Address2:  
City: LEWISBERRY
State: PA
PostalCode: 173399527
CountryCode: US
TelephoneNumber: 7179325200
FaxNumber: 7179323095
Other Information
ProviderEnumerationDate: 04/19/2007
LastUpdateDate: 01/17/2012
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
2085R0202XMD439800PAY Allopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
2085R0202XMT185836PAN Allopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology

ID Information
IDTypeStateIssuerDescription
102445928000105PA MEDICAID
41970460005MD MEDICAID


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