Provider Demographics
NPI:1063510220
Name:OTTO, JANET LYNN (MD)
Entity type:Individual
Prefix:
First Name:JANET
Middle Name:LYNN
Last Name:OTTO
Suffix:
Gender:F
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:PO BOX 277381
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-7381
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3200 CHANNING WAY STE 220
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7546
Practice Address - Country:US
Practice Address - Phone:208-800-6155
Practice Address - Fax:208-800-6158
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2025-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-14309207RC0001X, 207RC0000X
UT186150-8017207RC0000X
UT186150-1205207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT000016981OtherBCBS PIN
AZ719212Medicaid
WY113637200OtherMDCD PIN
MT314480OtherBCBS PIN
MT0011832OtherMDCD PIN
MT000016981OtherBCBS PIN
WY113637200OtherMDCD PIN
MT060052298Medicare PIN
MTG77924Medicare UPIN
MT000080957Medicare PIN
AZ719212Medicaid