Provider Demographics
NPI:1073602884
Name:OTTOLINI, MARY C (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:OTTOLINI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 MICHIGAN AVE NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20010-2978
Mailing Address - Country:US
Mailing Address - Phone:202-884-2182
Mailing Address - Fax:
Practice Address - Street 1:22 BRAMHALL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3134
Practice Address - Country:US
Practice Address - Phone:207-662-6711
Practice Address - Fax:207-662-6063
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD22944208M00000X
DCMD19738208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC024354500Medicaid
MD1822411100Medicaid
VA6725961Medicaid
DC0061OtherCAREFIRST
MD1822411100Medicaid