Healthcare Provider Details

I. General information

NPI: 1174525869
Provider Name (Legal Business Name): OTHON WILTZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 07/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3620 JOSEPH SIEWICK DR STE 406
FAIRFAX VA
22033-1761
US

IV. Provider business mailing address

3620 JOSEPH SIEWICK DR SUITE 406
FAIRFAX VA
22033
US

V. Phone/Fax

Practice location:
  • Phone: 703-359-8640
  • Fax: 703-591-6105
Mailing address:
  • Phone: 703-359-8640
  • Fax: 703-591-6105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number0101240155
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number11687
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: