Provider Demographics
NPI:1013990431
Name:GOYCO, OTTO
Entity Type:Individual
Prefix:
First Name:OTTO
Middle Name:
Last Name:GOYCO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4074 BOGAN BLUFF LN
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519-4501
Mailing Address - Country:US
Mailing Address - Phone:678-482-6886
Mailing Address - Fax:
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
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042473207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine