Healthcare Provider Details

I. General information

NPI: 1538145727
Provider Name (Legal Business Name): OTHELLO R REPUYAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/20/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3814 JAMES CT
ZANESVILLE OH
43701-0965
US

IV. Provider business mailing address

PO BOX 1821
ZANESVILLE OH
43702-1821
US

V. Phone/Fax

Practice location:
  • Phone: 740-454-7119
  • Fax: 740-455-5155
Mailing address:
  • Phone: 740-455-3304
  • Fax: 740-455-3686

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35041605R
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: