Individual
DR. LEO RYO OTAKE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D., PH.D,
Contact information
Practice address
722 POST RD, DARIEN, CT 06820
(203) 656-9999
Mailing address
722 POST RD, DARIEN, CT 06820-4744
(203) 656-9999
Taxonomy
Speciality
Code
Description
License number
State
208200000X
Plastic Surgery Physician
Primary
046053
CT
208200000X
Plastic Surgery Physician
246657
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
D400026606
INDIVIDUAL MEDICARE PTAN
CT
Enumeration date
02/07/2008
Last updated
05/14/2018
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