Provider Demographics
NPI:1063442937
Name:OU, MIKE W (MD)
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:W
Last Name:OU
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:119 AMBULANCE DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3857
Mailing Address - Country:US
Mailing Address - Phone:770-836-9250
Mailing Address - Fax:770-836-9261
Practice Address - Street 1:1125 E HIGHWAY 166
Practice Address - Street 2:
Practice Address - City:BOWDON
Practice Address - State:GA
Practice Address - Zip Code:30108-2401
Practice Address - Country:US
Practice Address - Phone:770-258-5424
Practice Address - Fax:770-838-8980
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2010-06-18
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Provider Licenses
StateLicense IDTaxonomies
GA053301207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H94285Medicare UPIN