Healthcare Provider Details

I. General information

NPI: 1457769234
Provider Name (Legal Business Name): SAM OBGARTEL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2014
Last Update Date: 02/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

843 MILLING AVE
LULING LA
70070-4442
US

IV. Provider business mailing address

2900 INDIANA AVE
KENNER LA
70065-4605
US

V. Phone/Fax

Practice location:
  • Phone: 504-575-3712
  • Fax: 504-575-3691
Mailing address:
  • Phone: 504-575-3712
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberAP07934
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: