Provider Demographics
NPI:1831146463
Name:HASTINGS, OTIS MARK (MD)
Entity Type:Individual
Prefix:
First Name:OTIS
Middle Name:MARK
Last Name:HASTINGS
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 1:28625 WOODMILL DR
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-2085
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14519 DETROIT AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-4316
Practice Address - Country:US
Practice Address - Phone:216-521-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35059241H207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH930007405OtherMEDICARE TRAVELERS RR-GA
OH942460636261OtherCARESOURCE
OH378646OtherWELLCARE
OH000000380930OtherANTHEM BC/BS
OH0798329Medicaid
OH341542312098OtherCARESOURCE
OH000000380930OtherANTHEM BC/BS
OH378646OtherWELLCARE
OH341542312098OtherCARESOURCE