Provider Demographics
NPI:1164418216
Name:OTTELIN, MARK CONRAD (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:CONRAD
Last Name:OTTELIN
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 1:509 N ELAM AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27403-1157
Mailing Address - Country:US
Mailing Address - Phone:336-274-1114
Mailing Address - Fax:336-232-5325
Practice Address - Street 1:509 N ELAM AVE FL 2
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27403-1157
Practice Address - Country:US
Practice Address - Phone:336-274-1114
Practice Address - Fax:336-232-5325
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2011-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC35458208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC64398OtherBLUE CROSS BLUE SHIELD
NC8964398Medicaid
NC2171346EMedicare PIN
NC2171346BMedicare PIN
NC64398OtherBLUE CROSS BLUE SHIELD
340017966Medicare PIN
NCC63946Medicare UPIN