Healthcare Provider Details

I. General information

NPI: 1194880906
Provider Name (Legal Business Name): YVONNE LYNN OTTAVIANO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2006
Last Update Date: 10/25/2023
Certification Date: 10/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9103 FRANKLING SQUARE DRIVE
ROSEDALE MD
21236
US

IV. Provider business mailing address

109 LONGWOOD RD
BALTIMORE MD
21210-2119
US

V. Phone/Fax

Practice location:
  • Phone: 443-777-7147
  • Fax: 443-777-8405
Mailing address:
  • Phone: 410-464-1658
  • Fax: 443-777-8405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License NumberD40850
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberMD482883
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: