Provider Demographics
NPI:1104844422
Name:OTIS, RAYMOND J SR (MD)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:J
Last Name:OTIS
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 348
Mailing Address - Street 2:24 NORTH ELLIS STREET
Mailing Address - City:CAMILLA
Mailing Address - State:GA
Mailing Address - Zip Code:31730-0348
Mailing Address - Country:US
Mailing Address - Phone:229-336-7343
Mailing Address - Fax:229-336-7400
Practice Address - Street 1:24 N ELLIS ST
Practice Address - Street 2:
Practice Address - City:CAMILLA
Practice Address - State:GA
Practice Address - Zip Code:31730-1502
Practice Address - Country:US
Practice Address - Phone:229-336-7343
Practice Address - Fax:229-336-7400
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA042685207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA08BDKVDMedicare ID - Type Unspecified