MEDICARE: LARITA L FRAZIER O'BANNON MD

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	207QA0505X	Adult Medicine Physician	35-063095	OH
2	207QG0300X	Geriatric Medicine (Family Medicine) Physician	35-063095	OH
3	207Q00000X	Family Medicine Physician	35.063095	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1588694541
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LARITA L FRAZIER O'BANNON MD

Provider Business Mailing Address
First Line	:	155 TRI COUNTY PKWY
Second Line	:	STE 240
City	:	CINCINNATI
State	:	OH
Zip	:	45246-3238
Country	:	US
Telephone Number	:	513-771-9888
Fax Number	:	513-771-3686

Provider Business Practice Location Address
First Line	:	4623 WESLEY AVE
Second Line	:	STE P
City	:	CINCINNATI
State	:	OH
Zip	:	45212-2246
Country	:	US
Telephone Number	:	513-841-0777
Fax Number	:	513-841-0877

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

Provider Enumeration Date	:	07/04/2006
Last Update Date	:	05/20/2013

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