Provider Demographics
NPI:1639517386
Name:TATUM, OWATHA LOYE (PHD, HCLD/CC(ABB))
Entity Type:Individual
Prefix:DR
First Name:OWATHA
Middle Name:LOYE
Last Name:TATUM
Suffix:
Gender:F
Credentials:PHD, HCLD/CC(ABB)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3415 56TH ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79413-4745
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3415 56TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79413-4745
Practice Address - Country:US
Practice Address - Phone:806-797-2879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-04
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDI43809247ZC0005X
NYTATU01246ZG1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physician
No246ZG1000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherGeneticist, Medical (PhD)