Provider Demographics
NPI:1194978445
Name:WHITCOMB, OTIS A
Entity type:Individual
Prefix:
First Name:OTIS
Middle Name:A
Last Name:WHITCOMB
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2187 SMOKE STONE CIR
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-6090
Mailing Address - Country:US
Mailing Address - Phone:678-361-1480
Mailing Address - Fax:
Practice Address - Street 1:627 CHEROKEE ST NE
Practice Address - Street 2:SUITE 9
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-8964
Practice Address - Country:US
Practice Address - Phone:770-590-8662
Practice Address - Fax:770-424-2099
Is Sole Proprietor?:No
Enumeration Date:2008-10-30
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA671237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist