Healthcare Provider Details

I. General information

NPI: 1669464004
Provider Name (Legal Business Name): JOE O OTHMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RR 2 BOX 169 GREYROCK PROFESS. PARK
LEWISBURG WV
24901-9316
US

IV. Provider business mailing address

RR02 BOX 169 GREYROCK PROFESS. PARK
LEWISBURG WV
24901-9316
US

V. Phone/Fax

Practice location:
  • Phone: 304-647-3040
  • Fax: 304-647-3835
Mailing address:
  • Phone: 304-647-3040
  • Fax: 304-647-3835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number15411
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: