Provider Demographics
NPI:1225998271
Name:OTSTOT, MARK RISEN
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:RISEN
Last Name:OTSTOT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3730 INGLESIDE BLVD APT 6402
Mailing Address - Street 2:
Mailing Address - City:LADSON
Mailing Address - State:SC
Mailing Address - Zip Code:29456-4453
Mailing Address - Country:US
Mailing Address - Phone:706-469-4782
Mailing Address - Fax:
Practice Address - Street 1:1906 BELLEVIEW AVE SE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-1838
Practice Address - Country:US
Practice Address - Phone:540-981-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-11-13
Last Update Date:2025-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program