Healthcare Provider Details

I. General information

NPI: 1003651282
Provider Name (Legal Business Name): SIDNEY OTIWU PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2024
Last Update Date: 06/28/2024
Certification Date: 06/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

575 PROFESSIONAL DR STE 370
LAWRENCEVILLE GA
30046-3334
US

IV. Provider business mailing address

2400 WISTERIA DR STE A
SNELLVILLE GA
30078-2689
US

V. Phone/Fax

Practice location:
  • Phone: 678-205-5420
  • Fax: 678-205-5462
Mailing address:
  • Phone: 770-982-0102
  • Fax: 770-982-0130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT017162
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: