Healthcare Provider Details

I. General information

NPI: 1700852639
Provider Name (Legal Business Name): LARRY L. OTEHAM D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2006
Last Update Date: 12/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 HOSPITAL WAY STE 101
SOMERSET KY
42503-2872
US

IV. Provider business mailing address

350 HOSPITAL WAY STE 100
SOMERSET KY
42503-1872
US

V. Phone/Fax

Practice location:
  • Phone: 606-451-5092
  • Fax:
Mailing address:
  • Phone: 606-451-5087
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberTP847
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: