Provider Demographics
NPI:1679689566
Name:DEAL, BAXTER OLIVER III (MPT, LOTR)
Entity Type:Individual
Prefix:MR
First Name:BAXTER
Middle Name:OLIVER
Last Name:DEAL
Suffix:III
Gender:M
Credentials:MPT, LOTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2002 JOHNSON ST
Mailing Address - Street 2:STE 100
Mailing Address - City:JENNINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70546-3640
Mailing Address - Country:US
Mailing Address - Phone:337-824-4547
Mailing Address - Fax:337-824-4548
Practice Address - Street 1:2002 JOHNSON ST
Practice Address - Street 2:SUITE 100
Practice Address - City:JENNINGS
Practice Address - State:LA
Practice Address - Zip Code:70546-3646
Practice Address - Country:US
Practice Address - Phone:337-824-4547
Practice Address - Fax:337-824-4548
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA05284225100000X
LAOTT.Z12349225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1467898Medicaid
LA1178543Medicaid
LA4C639CB91Medicare ID - Type UnspecifiedMC-OT LINKED TO TTC
LA4C639Medicare ID - Type UnspecifiedMC-OT #
LA4C640CB91Medicare ID - Type UnspecifiedMC-PT LINKED TO TTC
LA1467898Medicaid