Provider Demographics
NPI:1245224559
Name:BARNUM, OTIS R (DO)
Entity type:Individual
Prefix:
First Name:OTIS
Middle Name:R
Last Name:BARNUM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:617 BIENVILLE ST STE A
Mailing Address - Street 2:
Mailing Address - City:NATCHITOCHES
Mailing Address - State:LA
Mailing Address - Zip Code:71457-5740
Mailing Address - Country:US
Mailing Address - Phone:318-352-9880
Mailing Address - Fax:318-357-1347
Practice Address - Street 1:617 BIENVILLE ST
Practice Address - Street 2:
Practice Address - City:NATCHITOCHES
Practice Address - State:LA
Practice Address - Zip Code:71457-5739
Practice Address - Country:US
Practice Address - Phone:318-352-9880
Practice Address - Fax:318-357-1347
Is Sole Proprietor?:No
Enumeration Date:2005-09-01
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA018855207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1361984Medicaid
B63505Medicare UPIN
5CP89Medicare ID - Type Unspecified