Healthcare Provider Details

I. General information

NPI: 1912438185
Provider Name (Legal Business Name): JOSEPH OTTOLENGHI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2017
Last Update Date: 10/14/2021
Certification Date: 10/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 E KINCAID ST
MOUNT VERNON WA
98274-4127
US

IV. Provider business mailing address

1400 E KINCAID ST
MOUNT VERNON WA
98274-4127
US

V. Phone/Fax

Practice location:
  • Phone: 360-428-2575
  • Fax: 360-428-6471
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD61184062
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: