Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QG0300X | Family Doctor - Geriatric Medicine | 010682 | LA |
NPI | 1043201312 |
---|---|
Provider Name | David Henry |
First Address | Shreveport, LA 71105-5505 |
Second Address | Shreveport, LA 71105-5505 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/11/2005 |
Last Update Date | 20/12/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
106736503 | (05) | TX |
1096156 | (05) | LA |
B60458 | (02) |