Provider Demographics
NPI:1043214323
Name:WARR, OTIS SUMTER IV (MD)
Entity type:Individual
Prefix:DR
First Name:OTIS
Middle Name:SUMTER
Last Name:WARR
Suffix:IV
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 1:555 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72653-3409
Mailing Address - Country:US
Mailing Address - Phone:870-425-8288
Mailing Address - Fax:870-425-8299
Practice Address - Street 1:555 W 6TH ST
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-3409
Practice Address - Country:US
Practice Address - Phone:870-425-8288
Practice Address - Fax:870-425-8299
Is Sole Proprietor?:No
Enumeration Date:2005-06-02
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE3744174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR150550001Medicaid
AR03120015100OtherQUAL CHOICE #
ARA005OtherCHAMPUS/TRICARE #
AR5M662OtherAR BCBS #
ARA005OtherCHAMPUS/TRICARE #
AR03120015100OtherQUAL CHOICE #
ARH31611Medicare UPIN