Provider Demographics
NPI:1568495067
Name:TIMMONS, OTWELL DUDLEY (MD)
Entity Type:Individual
Prefix:
First Name:OTWELL
Middle Name:DUDLEY
Last Name:TIMMONS
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1001 BLYTHE BLVD
Practice Address - Street 2:MEDICAL CENTER PLAZA SUITE 200
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5866
Practice Address - Country:US
Practice Address - Phone:704-381-8840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9300610208000000X, 2080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7983540Medicaid
NC83540OtherNCBCBS
SCN00610Medicaid
NC1568495067Medicaid
SCN00610Medicaid
NC2298881AMedicare PIN
NC1568495067Medicaid