# DR. OTIS J BOURG JR.

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- **Entity:** Individual
- **Status:** Active
- **Sole proprietor:** Yes

## Provider details

- **NPI number:** 1114009313
- **Gender:** Man
- **Credential:** O. D.

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 152W00000X | Optometrist | LA666265T | LA | Yes |

## Other

- **Enumeration date:** 10/19/2006
- **Last updated:** 03/11/2009

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 06110 | SPECTERA | LA |
| 05 | — | 1094196 | — | LA |
| 01 | — | 110894 | EYE MED | LA |
| 01 | — | BO908019 | CLARITY VISION | LA |