Provider Demographics
NPI:1255372967
Name:OTTO, MARILYN MARJORIE (MD)
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:MARJORIE
Last Name:OTTO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5170 US RT 60 E
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25705
Mailing Address - Country:US
Mailing Address - Phone:304-528-4619
Mailing Address - Fax:304-399-0133
Practice Address - Street 1:5170 US RT 60 E
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25705
Practice Address - Country:US
Practice Address - Phone:304-528-4619
Practice Address - Fax:304-399-0133
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV17217207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0075595000Medicaid
OH0921471Medicaid
F62083Medicare UPIN
OH0921471Medicaid