Provider Demographics
NPI:1710938089
Name:OTTAVIANI, ROBERT E (DC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:E
Last Name:OTTAVIANI
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:727 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:FREELAND
Mailing Address - State:PA
Mailing Address - Zip Code:18224-1424
Mailing Address - Country:US
Mailing Address - Phone:570-636-1132
Mailing Address - Fax:
Practice Address - Street 1:727 WALNUT ST
Practice Address - Street 2:
Practice Address - City:FREELAND
Practice Address - State:PA
Practice Address - Zip Code:18224-1424
Practice Address - Country:US
Practice Address - Phone:570-636-1132
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC001477L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0631313Medicaid
PA167870Medicare ID - Type Unspecified
PA0631313Medicaid