Provider Demographics
NPI:1992782544
Name:GOWDY, OTIS JR (MD)
Entity type:Individual
Prefix:DR
First Name:OTIS
Middle Name:
Last Name:GOWDY
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 749215
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-9215
Mailing Address - Country:US
Mailing Address - Phone:901-226-3186
Mailing Address - Fax:
Practice Address - Street 1:1600 22ND AVE
Practice Address - Street 2:MEDICAL TOWERS III
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-3223
Practice Address - Country:US
Practice Address - Phone:601-483-5322
Practice Address - Fax:601-581-2289
Is Sole Proprietor?:No
Enumeration Date:2005-12-26
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17024207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01281539Medicaid
MSI33849Medicare UPIN
MS110001876Medicare ID - Type Unspecified