Provider Demographics
NPI:1871550780
Name:OTTEY, DERON C K (MD)
Entity type:Individual
Prefix:DR
First Name:DERON
Middle Name:C K
Last Name:OTTEY
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 1:115 E 19TH ST
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-5110
Mailing Address - Country:US
Mailing Address - Phone:575-622-7600
Mailing Address - Fax:
Practice Address - Street 1:115 E 19TH ST
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5110
Practice Address - Country:US
Practice Address - Phone:575-622-7600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2024-1070207X00000X
FLME112364207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMMD2024-1070OtherNM LICENSE