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General NPI Number Information
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NPI Number | 1174525869
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Entity Type | Individual
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Provider Name | OTHON WILTZ M.D.
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Gender | Male
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Dates
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Enumeration Date | 08/11/2005
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Last Update Date | 07/25/2017
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Provider Practice Location Address
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Address Line | 3620 JOSEPH SIEWICK DR STE 406
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City | FAIRFAX
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State | VA
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Zip | 22033-1761
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Country | US
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Telephone | 703-359-8640
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Fax | 703-591-6105
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Provider Business Mailing Address
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Address Line | 3620 JOSEPH SIEWICK DR SUITE 406
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City | FAIRFAX
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State | VA
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Zip | 22033
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Country | US
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Telephone | 703-359-8640
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Fax | 703-591-6105
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208C00000X
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Taxonomy Name | Colon & Rectal Surgery Physician
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License Number | 0101240155
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 208C00000X
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Taxonomy Name | Colon & Rectal Surgery Physician
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License Number | 11687
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License Number State | PR
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