Basic Information
| Provider Information | |||||||||
| NPI: | 1174525869 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILTZ | ||||||||
| FirstName: | OTHON | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3620 JOSEPH SIEWICK DR | ||||||||
| Address2: | SUITE 406 | ||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 22033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7033598640 | ||||||||
| FaxNumber: | 7035916105 | ||||||||
| Practice Location | |||||||||
| Address1: | 3620 JOSEPH SIEWICK DR STE 406 | ||||||||
| Address2: | |||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220331761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7033598640 | ||||||||
| FaxNumber: | 7035916105 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2005 | ||||||||
| LastUpdateDate: | 07/25/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208C00000X | 0101240155 | VA | Y | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery | 208C00000X | 11687 | PR | N | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery |
ID Information
| ID | Type | State | Issuer | Description | 060957 | 01 | PR | LA CRUZ AZUL | OTHER | 601049 | 01 | PR | MMM | OTHER | SE4019 | 01 | PR | PALIC | OTHER | 1174525869 | 05 | VA | MEDICAID | 1400005 | 01 | PR | HUMANA | OTHER | 311678 | 01 | PR | CIGNA | OTHER | 7113 | 01 | PR | IMC | OTHER | 89937 | 01 | PR | SSS | OTHER |