Provider Demographics
NPI:1114959202
Name:OTTAVIANO, PETER (DO)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:OTTAVIANO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1249 15TH ST
Mailing Address - Street 2:SUITE 3000
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-3662
Mailing Address - Country:US
Mailing Address - Phone:304-691-1000
Mailing Address - Fax:304-691-1693
Practice Address - Street 1:1249 15TH ST
Practice Address - Street 2:SUITE 3000
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-3662
Practice Address - Country:US
Practice Address - Phone:304-691-1000
Practice Address - Fax:304-691-1693
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1144207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0042458000Medicaid
KY6407504Medicaid
OH0917128Medicaid
290005124OtherRAILROAD MEDICARE
E41422Medicare UPIN
0655443Medicare PIN