Healthcare Provider Details

I. General information

NPI: 1528201480
Provider Name (Legal Business Name): BERT B OUBRE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2009
Last Update Date: 09/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 E MAIN ST SUITE C
LEXINGTON SC
29072-3729
US

IV. Provider business mailing address

602 E MAIN ST SUITE C
LEXINGTON SC
29072-3729
US

V. Phone/Fax

Practice location:
  • Phone: 803-359-0164
  • Fax: 803-359-0255
Mailing address:
  • Phone: 803-359-0164
  • Fax: 803-359-0255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number30244
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: