Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208000000X | Pediatrician | MD.206784 | LA |
N | 2080P0203X | Pediatric Critical Care Doctor | MD.206784 | LA |
NPI | 1013107614 |
---|---|
Provider Name | Marco Quispe Leveau |
First Address | Shreveport, LA 71103-3822 |
Second Address | Shreveport, LA 71103-4228 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/07/2007 |
Last Update Date | 09/10/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1509761 | (05) | LA |