Healthcare Provider Details

I. General information

NPI: 1992431753
Provider Name (Legal Business Name): OTIS PRESTIGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2022
Last Update Date: 07/25/2022
Certification Date: 07/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 ANDERSON ST SE STE 200A
MARIETTA GA
30060-8610
US

IV. Provider business mailing address

55 ATLANTA ST SE STE 101
MARIETTA GA
30060-1977
US

V. Phone/Fax

Practice location:
  • Phone: 470-301-8528
  • Fax:
Mailing address:
  • Phone: 470-301-8528
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: DAMIAN DRAGO
Title or Position: ADMINISTRATOR
Credential: ARNP
Phone: 470-301-8528