Provider Demographics
NPI:1174525869
Name:WILTZ, OTHON (MD)
Entity type:Individual
Prefix:
First Name:OTHON
Middle Name:
Last Name:WILTZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3620 JOSEPH SIEWICK DR
Mailing Address - Street 2:SUITE 406
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033
Mailing Address - Country:US
Mailing Address - Phone:703-359-8640
Mailing Address - Fax:703-591-6105
Practice Address - Street 1:3620 JOSEPH SIEWICK DR STE 406
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-1761
Practice Address - Country:US
Practice Address - Phone:703-359-8640
Practice Address - Fax:703-591-6105
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2017-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101240155208C00000X
PR11687208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR060957OtherLA CRUZ AZUL
PR601049OtherMMM
PRSE4019OtherPALIC
VA1174525869Medicaid
PR1400005OtherHUMANA
PR311678OtherCIGNA
PR7113OtherIMC
PR89937OtherSSS
PRF50723Medicare UPIN