Healthcare Provider Details

I. General information

NPI: 1346222908
Provider Name (Legal Business Name): VICTOR OTROSZKO A.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2005
Last Update Date: 06/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 MEDICAL WAY
SNELLVILLE GA
30078-2195
US

IV. Provider business mailing address

PO BOX 3559
SUWANEE GA
30024-0993
US

V. Phone/Fax

Practice location:
  • Phone: 770-979-9996
  • Fax:
Mailing address:
  • Phone: 770-979-9996
  • Fax: 770-979-1202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number002571
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: