Provider Demographics
NPI:1447267026
Name:OTT, CASEY (MD)
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:OTT
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 1:22 OLD WATERBURY RD # 103
Mailing Address - Street 2:
Mailing Address - City:SOUTHBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06488-3848
Mailing Address - Country:US
Mailing Address - Phone:203-262-1200
Mailing Address - Fax:
Practice Address - Street 1:22 OLD WATERBURY RD # 103
Practice Address - Street 2:
Practice Address - City:SOUTHBURY
Practice Address - State:CT
Practice Address - Zip Code:06488-3848
Practice Address - Country:US
Practice Address - Phone:203-262-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT038781207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTH18234Medicare UPIN