Provider Demographics
NPI:1992431753
Name:OTIS PRESTIGE
Entity type:Organization
Organization Name:OTIS PRESTIGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DAMIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DRAGO
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:470-301-8528
Mailing Address - Street 1:55 ATLANTA ST SE STE 101
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1977
Mailing Address - Country:US
Mailing Address - Phone:470-301-8528
Mailing Address - Fax:
Practice Address - Street 1:109 ANDERSON ST SE STE 200A
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-8610
Practice Address - Country:US
Practice Address - Phone:470-301-8528
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-25
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA4703018528Other4703018528