MEDICARE: DR. DIANA M OTTULICH MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	0101280042	VA
2	390200000X	Student in an Organized Health Care Education/Training Program
3	171000000X	Military Health Care Provider	0101280042	VA

General Provider Information

NPI Number	:	1629715552
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DIANA M OTTULICH MD

Provider Business Mailing Address
First Line	:	822 CLARK ST
Second Line	:
City	:	PEARL HARBOR
State	:	HI
Zip	:	96860-4652
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	822 CLARK ST
Second Line	:
City	:	PEARL HARBOR
State	:	HI
Zip	:	96860-4652
Country	:	US
Telephone Number	:	757-836-5929
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/12/2022
Last Update Date	:	05/28/2024

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