Provider Demographics
NPI:1477315877
Name:BARRETT, OTASH
Entity Type:Individual
Prefix:
First Name:OTASH
Middle Name:
Last Name:BARRETT
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 1:13156 ROYAL PINES AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33579-9321
Mailing Address - Country:US
Mailing Address - Phone:813-516-7886
Mailing Address - Fax:
Practice Address - Street 1:13156 ROYAL PINES AVE
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33579-9321
Practice Address - Country:US
Practice Address - Phone:813-516-7886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-30
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLB630643750190172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver