Provider Demographics
NPI:1588694541
Name:FRAZIER O'BANNON, LARITA L (MD)
Entity type:Individual
Prefix:
First Name:LARITA
Middle Name:L
Last Name:FRAZIER O'BANNON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:155 TRI COUNTY PKWY
Mailing Address - Street 2:STE 240
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45246-3238
Mailing Address - Country:US
Mailing Address - Phone:513-771-9888
Mailing Address - Fax:513-771-3686
Practice Address - Street 1:4623 WESLEY AVE
Practice Address - Street 2:STE P
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45212-2246
Practice Address - Country:US
Practice Address - Phone:513-841-0777
Practice Address - Fax:513-841-0877
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-063095207QA0505X, 207QG0300X
OH35.063095207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0904703Medicaid
OH0904703Medicaid