Healthcare Provider Details

I. General information

NPI: 1548409246
Provider Name (Legal Business Name): OLIVER JOHN BARTON PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/19/2009
Last Update Date: 02/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 W HAVENS AVE
MITCHELL SD
57301-3831
US

IV. Provider business mailing address

910 W HAVENS AVE
MITCHELL SD
57301-3831
US

V. Phone/Fax

Practice location:
  • Phone: 605-996-9686
  • Fax: 605-996-1624
Mailing address:
  • Phone: 605-996-9686
  • Fax: 605-996-1624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPENDING
License Number StateSD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier5200110
Identifier TypeMEDICAID
Identifier StateSD
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: