Provider Demographics
NPI:1205885597
Name:OTTENI, JACK F (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:F
Last Name:OTTENI
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 1:70 MEDICAL CENTER CIR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:FISHERSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22939-2273
Mailing Address - Country:US
Mailing Address - Phone:540-332-5850
Mailing Address - Fax:540-332-5851
Practice Address - Street 1:70 MEDICAL CENTER CIR
Practice Address - Street 2:SUITE 110
Practice Address - City:FISHERSVILLE
Practice Address - State:VA
Practice Address - Zip Code:22939-2273
Practice Address - Country:US
Practice Address - Phone:540-332-5850
Practice Address - Fax:540-332-5851
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101234631207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006410031Medicaid
VA001722050Medicare ID - Type Unspecified
VAH63402Medicare UPIN