Provider Demographics
NPI:1588663819
Name:LEFTWICH, OWEN BERNARD (MD)
Entity Type:Individual
Prefix:DR
First Name:OWEN
Middle Name:BERNARD
Last Name:LEFTWICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4601 WICHERS DR
Mailing Address - Street 2:
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-3049
Mailing Address - Country:US
Mailing Address - Phone:504-347-8434
Mailing Address - Fax:504-347-9868
Practice Address - Street 1:4601 WICHERS DR
Practice Address - Street 2:
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-3049
Practice Address - Country:US
Practice Address - Phone:504-347-8434
Practice Address - Fax:504-347-9868
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAL015702174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1350885Medicaid
LA1350885Medicaid
LAB61993Medicare UPIN
LA5M759B894Medicare PIN