Provider Demographics
NPI:1245487404
Name:OTU-NYARKO, CHARLES GODFRIED (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:GODFRIED
Last Name:OTU-NYARKO
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 1:2508 BERT KOUNS LOOP
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-3133
Mailing Address - Country:US
Mailing Address - Phone:318-212-5858
Mailing Address - Fax:318-212-5877
Practice Address - Street 1:2508 BERT KOUNS LOOP
Practice Address - Street 2:SUITE 101
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-3133
Practice Address - Country:US
Practice Address - Phone:318-212-5858
Practice Address - Fax:318-212-5877
Is Sole Proprietor?:No
Enumeration Date:2008-08-19
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.052705208000000X
LAMD.2038192080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2107259Medicaid