Provider Demographics
NPI:1447328299
Name:OTT, SUSAN MARIE (DO)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:OTT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1575 RAMBLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-6384
Mailing Address - Country:US
Mailing Address - Phone:989-725-6528
Mailing Address - Fax:989-723-9446
Practice Address - Street 1:113 E WILLIAMS ST
Practice Address - Street 2:
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867-2360
Practice Address - Country:US
Practice Address - Phone:989-725-6101
Practice Address - Fax:989-723-3601
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101012156207X00000X
FLOS8868207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1447328299Medicaid
MIN53550106Medicare PIN
FLH05352Medicare UPIN