Healthcare Provider Details

I. General information

NPI: 1194978445
Provider Name (Legal Business Name): OTIS A WHITCOMB
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2008
Last Update Date: 06/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

627 CHEROKEE ST NE SUITE 9
MARIETTA GA
30060-8964
US

IV. Provider business mailing address

2187 SMOKE STONE CIR
MARIETTA GA
30062-6090
US

V. Phone/Fax

Practice location:
  • Phone: 770-590-8662
  • Fax: 770-424-2099
Mailing address:
  • Phone: 678-361-1480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number671
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: