Provider Demographics
NPI:1437861325
Name:OATIS, JR, DERRICK MONTRELLE
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:MONTRELLE
Last Name:OATIS, JR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1761 N 19TH ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-4554
Mailing Address - Country:US
Mailing Address - Phone:318-509-8073
Mailing Address - Fax:318-703-5765
Practice Address - Street 1:1761 N 19TH ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-4554
Practice Address - Country:US
Practice Address - Phone:318-509-8073
Practice Address - Fax:318-703-5765
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-22
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator