Healthcare Provider Details

I. General information

NPI: 1841877628
Provider Name (Legal Business Name): OTASOWIE MICHAEL ODIASE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2021
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 MARTIN F GIBBONS BLVD
DICKSON CITY PA
18519-1787
US

IV. Provider business mailing address

100 N ACADEMY AVE
DANVILLE PA
17822-4903
US

V. Phone/Fax

Practice location:
  • Phone: 570-846-2340
  • Fax: 570-846-2341
Mailing address:
  • Phone: 570-846-2340
  • Fax: 570-846-2341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberMD495600
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: