Provider Demographics
NPI:1598782534
Name:OTTO C GOYCO MD INTERNAL MEDICINE LLC
Entity Type:Organization
Organization Name:OTTO C GOYCO MD INTERNAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OTTO
Authorized Official - Middle Name:C
Authorized Official - Last Name:GOYCO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-781-8840
Mailing Address - Street 1:900 SANDERS RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-5960
Mailing Address - Country:US
Mailing Address - Phone:770-781-8840
Mailing Address - Fax:770-781-8098
Practice Address - Street 1:900 SANDERS RD
Practice Address - Street 2:SUITE B
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-5960
Practice Address - Country:US
Practice Address - Phone:770-781-8840
Practice Address - Fax:770-781-8098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042473207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000752903MMedicaid
GA11BDWJQMedicare ID - Type Unspecified
GA000752903MMedicaid