Provider Demographics
NPI:1891712626
Name:SCHWARZ, OTTO STEPHAN (MD)
Entity Type:Individual
Prefix:
First Name:OTTO
Middle Name:STEPHAN
Last Name:SCHWARZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:OTTO
Other - Middle Name:STEPHAN
Other - Last Name:SCHWARZ VIGNOLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1000 MEDICAL CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-7694
Mailing Address - Country:US
Mailing Address - Phone:678-312-2418
Mailing Address - Fax:678-312-2434
Practice Address - Street 1:1000 MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-7694
Practice Address - Country:US
Practice Address - Phone:678-312-2418
Practice Address - Fax:678-312-2434
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA064264207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
MNENROLLEDMedicaid