Provider Demographics
NPI:1114009313
Name:BOURG, OTIS J JR (O D)
Entity Type:Individual
Prefix:DR
First Name:OTIS
Middle Name:J
Last Name:BOURG
Suffix:JR
Gender:M
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:832 BELANGER ST
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70360-4408
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:832 BELANGER ST
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360-4408
Practice Address - Country:US
Practice Address - Phone:985-872-1494
Practice Address - Fax:985-580-4422
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2009-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA666265T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1094196Medicaid
LA110894OtherEYE MED
LA06110OtherSPECTERA
LABO908019OtherCLARITY VISION
LABO908019OtherCLARITY VISION
LA06110OtherSPECTERA