Individual
MARK CONRAD OTTELIN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
509 N ELAM AVE FL 2, GREENSBORO, NC 27403-1157
(336) 274-1114
(336) 232-5325
Mailing address
509 N ELAM AVE FL 2, GREENSBORO, NC 27403-1157
(336) 274-1114
(336) 232-5325
Taxonomy
Speciality
Code
Description
License number
State
208800000X
Urology Physician
Primary
35458
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
64398
BLUE CROSS BLUE SHIELD
NC
05
—
8964398
—
NC
Enumeration date
09/23/2005
Last updated
02/11/2011
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