Provider Demographics
NPI:1104824069
Name:PLUNK, OTIS A (MD)
Entity Type:Individual
Prefix:
First Name:OTIS
Middle Name:A
Last Name:PLUNK
Suffix:
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 1:1140 HAMMOND DR NE
Mailing Address - Street 2:BUILDING I, STE 9100
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-5338
Mailing Address - Country:US
Mailing Address - Phone:770-393-1362
Mailing Address - Fax:770-393-1743
Practice Address - Street 1:1140 HAMMOND DR NE
Practice Address - Street 2:BUILDING I, STE 9100
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-5338
Practice Address - Country:US
Practice Address - Phone:770-393-1362
Practice Address - Fax:770-393-1743
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA054852207PS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAA11406Medicare UPIN