Provider Demographics
NPI:1902080609
Name:OTA, BRIAN S (DC)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:S
Last Name:OTA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1052 E EL CAMINO REAL
Mailing Address - Street 2:
Mailing Address - City:SUNNYVALE
Mailing Address - State:CA
Mailing Address - Zip Code:94087-3754
Mailing Address - Country:US
Mailing Address - Phone:408-248-7960
Mailing Address - Fax:408-554-0654
Practice Address - Street 1:150 E FREMONT AVE
Practice Address - Street 2:
Practice Address - City:SUNNYVALE
Practice Address - State:CA
Practice Address - Zip Code:94087-3201
Practice Address - Country:US
Practice Address - Phone:408-720-0941
Practice Address - Fax:408-720-0943
Is Sole Proprietor?:No
Enumeration Date:2007-12-18
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23084111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ40577ZOtherBLUE SHIELD
CAZZZ40577ZOtherBLUE SHIELD