Healthcare Provider Details

I. General information

NPI: 1932849601
Provider Name (Legal Business Name): BRENTON KYLE OTEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2022
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

743 SPRING ST NE REAR 710
GAINESVILLE GA
30501-3899
US

IV. Provider business mailing address

3650 STEVE REYNOLDS BLVD
DULUTH GA
30096-4506
US

V. Phone/Fax

Practice location:
  • Phone: 770-219-8730
  • Fax:
Mailing address:
  • Phone: 404-365-0966
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number114565
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: