MEDICARE: DR. OTIS COSBY JR. M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2083X0100X	Occupational Medicine Physician	MD021929	TN
2	2083X0100X	Occupational Medicine Physician	36492	SC
3	2083X0100X	Occupational Medicine Physician	2020-03013	NC

General Provider Information

NPI Number	:	1720341191
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. OTIS COSBY JR. M.D.

Provider Business Mailing Address
First Line	:	PO BOX 744786
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30374-4786
Country	:	US
Telephone Number	:	704-834-2450
Fax Number	:	704-671-5331

Provider Business Practice Location Address
First Line	:	2555 COURT DR STE 120
Second Line	:
City	:	GASTONIA
State	:	NC
Zip	:	28054-2177
Country	:	US
Telephone Number	:	704-834-3070
Fax Number	:	704-834-3073

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/20/2012
Last Update Date	:	04/01/2022

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