Provider Demographics
NPI:1063917581
Name:OTTOFARO, TREVOR DALE (MD)
Entity type:Individual
Prefix:
First Name:TREVOR
Middle Name:DALE
Last Name:OTTOFARO
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:PO BOX 715868
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19171-5868
Mailing Address - Country:US
Mailing Address - Phone:804-915-1910
Mailing Address - Fax:804-968-1810
Practice Address - Street 1:1115 BOULDERS PKWY STE 100
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23225-4067
Practice Address - Country:US
Practice Address - Phone:804-320-1339
Practice Address - Fax:804-330-5829
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-27
Last Update Date:2025-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA100649207X00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty