Provider Demographics
NPI:1740305275
Name:JOE O OTHMAN MD INC
Entity type:Organization
Organization Name:JOE O OTHMAN MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOE
Authorized Official - Middle Name:O
Authorized Official - Last Name:OTHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-647-3040
Mailing Address - Street 1:RR 2 BOX 169
Mailing Address - Street 2:GREYROCK PROFESS. PARK
Mailing Address - City:LEWISBURG
Mailing Address - State:WV
Mailing Address - Zip Code:24901-9316
Mailing Address - Country:US
Mailing Address - Phone:304-647-3040
Mailing Address - Fax:304-647-3835
Practice Address - Street 1:RR 2 BOX 169
Practice Address - Street 2:GREYROCK PROFESS. PARK
Practice Address - City:LEWISBURG
Practice Address - State:WV
Practice Address - Zip Code:24901-9316
Practice Address - Country:US
Practice Address - Phone:304-647-3040
Practice Address - Fax:304-647-3835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV154112084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0089749000Medicaid
WV9268691OtherMEDICARE PTAN