Individual
RANDALL JASON OTTO
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1011 BOWLES AVE STE 400, FENTON, MO 63026-2387
(314) 977-7200
(636) 326-6533
Mailing address
1008 S SPRING AVE FL 1, SAINT LOUIS, MO 63110-2520
(314) 977-5350
(314) 977-1629
Taxonomy
Speciality
Code
Description
License number
State
207X00000X
Orthopaedic Surgery Physician
Primary
2012011162
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
122950063
MEDICARE PTAN
MO
01
—
136637
HEALTHCARE USA
MO
01
—
4258558
CIGNA
MO
05
—
501357701
—
MO
01
—
771091
ANTHEM BLUE CROSS BLUE SHIELD
MO
01
—
A82171
HEALTHLINK
MO
Enumeration date
06/14/2007
Last updated
02/24/2021
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