Basic Information
| Provider Information | |||||||||
| NPI: | 1245362706 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STITT | ||||||||
| FirstName: | OTIS | ||||||||
| MiddleName: | LAWRENCE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26005 RIDGE RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | DAMASCUS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208721899 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3014142300 | ||||||||
| FaxNumber: | 3014142306 | ||||||||
| Practice Location | |||||||||
| Address1: | 26005 RIDGE RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | DAMASCUS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208721899 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3014142300 | ||||||||
| FaxNumber: | 3014142306 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2007 | ||||||||
| LastUpdateDate: | 10/10/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | D0065873 | MD | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 060723100 | 05 | MD | MEDICAID |