Provider Demographics
NPI:1700671492
Name:OTTWELL DERMATOLOGY PLLC
Entity type:Organization
Organization Name:OTTWELL DERMATOLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:LUCAS
Authorized Official - Last Name:OTTWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:918-991-8718
Mailing Address - Street 1:6224 S 223RD EAST AVE
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74014-2029
Mailing Address - Country:US
Mailing Address - Phone:918-991-8718
Mailing Address - Fax:
Practice Address - Street 1:3915 E 51ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-3605
Practice Address - Country:US
Practice Address - Phone:918-991-8718
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-04-12
Last Update Date:2025-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty