Individual
SCOTT IRELAND OTALLAH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
MEDICAL CENTER BLVD, WINSTON SALEM, NC 27157-2256
(336) 716-2255
Mailing address
MEDICAL CENTER BLVD, WINSTON-SALEM, NC 27157-0001
(336) 716-2255
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
0101-255657
VA
208000000X
Pediatrics Physician
2009017502
MO
2084N0400X
Neurology Physician
Primary
2017-01481
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
VVE342A
MEDICARE PTAN
VA
Enumeration date
07/06/2009
Last updated
08/29/2017
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