Healthcare Provider Details

I. General information

NPI: 1245487404
Provider Name (Legal Business Name): CHARLES GODFRIED OTU-NYARKO M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2008
Last Update Date: 05/14/2021
Certification Date: 04/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2508 BERT KOUNS LOOP SUITE 101
SHREVEPORT LA
71118-3133
US

IV. Provider business mailing address

2508 BERT KOUNS LOOP SUITE 101
SHREVEPORT LA
71118-3133
US

V. Phone/Fax

Practice location:
  • Phone: 318-212-5858
  • Fax: 318-212-5877
Mailing address:
  • Phone: 318-212-5858
  • Fax: 318-212-5877

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125.052705
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License NumberMD.203819
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: