Provider Demographics
NPI:1073674925
Name:OETGEN, WILLIAM JOHN (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:JOHN
Last Name:OETGEN
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 1:647 FIRST ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-1511
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12070 OLD LINE CTR
Practice Address - Street 2:SUITE 100
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-2513
Practice Address - Country:US
Practice Address - Phone:301-705-7870
Practice Address - Fax:301-705-9622
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2009-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0016129174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD463921900Medicaid
MD463921900Medicaid
MD454L246TMedicare PIN
DC157722M92Medicare PIN
MDO60039318Medicare PIN
MD136953Y3NMedicare PIN