Provider Demographics
NPI:1740302066
Name:OTELLIN, ALEXANDER VLADIMIROVICH (MD)
Entity type:Individual
Prefix:DR
First Name:ALEXANDER
Middle Name:VLADIMIROVICH
Last Name:OTELLIN
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 1:401 DIVISION ST STE 307
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1455
Mailing Address - Country:US
Mailing Address - Phone:304-932-4259
Mailing Address - Fax:
Practice Address - Street 1:401 DIVISION ST STE 307
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1455
Practice Address - Country:US
Practice Address - Phone:304-932-4259
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV225922084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810009290Medicaid
WVOT4213191Medicare PIN