Healthcare Provider Details

I. General information

NPI: 1104844422
Provider Name (Legal Business Name): RAYMOND J OTIS SR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 05/21/2024
Certification Date: 05/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 N ELLIS ST
CAMILLA GA
31730-1502
US

IV. Provider business mailing address

PO BOX 348 24 NORTH ELLIS STREET
CAMILLA GA
31730-0348
US

V. Phone/Fax

Practice location:
  • Phone: 229-336-7343
  • Fax: 229-336-7400
Mailing address:
  • Phone: 229-336-7343
  • Fax: 229-336-7400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number042685
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: