MEDICARE: LARRY O OTWELL AUD CCCA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	231H00000X	Audiologist	AY370	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	AD782	OTHER	FL	MEDICARE GROUP
2	K0176	OTHER	FL	MEDICARE OLD PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	S1844	OTHER	FL	BCBS
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417941329
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LARRY O OTWELL AUD CCCA

Provider Business Mailing Address
First Line	:	2518 S HIGHWAY 77 STE A
Second Line	:
City	:	LYNN HAVEN
State	:	FL
Zip	:	32444-4730
Country	:	US
Telephone Number	:	850-769-2705
Fax Number	:	850-769-1097

Provider Business Practice Location Address
First Line	:	2518 S HIGHWAY 77 STE A
Second Line	:
City	:	LYNN HAVEN
State	:	FL
Zip	:	32444-4730
Country	:	US
Telephone Number	:	850-769-2705
Fax Number	:	850-769-1097

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/07/2005
Last Update Date	:	04/03/2013

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