Provider Demographics
NPI:1285654301
Name:POWELL, OTIS SAMUEL JR (MD)
Entity Type:Individual
Prefix:DR
First Name:OTIS
Middle Name:SAMUEL
Last Name:POWELL
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:OTIS
Other - Middle Name:S
Other - Last Name:POWELL
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:777 CLEVELAND AVE SW STE 500
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30315-7115
Mailing Address - Country:US
Mailing Address - Phone:404-755-2291
Mailing Address - Fax:404-755-5377
Practice Address - Street 1:777 CLEVELAND AVE SW STE 500
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30315-7115
Practice Address - Country:US
Practice Address - Phone:404-755-2291
Practice Address - Fax:404-755-5377
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA025814207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00309845GMedicaid
GA08BDKWSMedicare ID - Type Unspecified
GA00309845GMedicaid