MEDICARE: DR. MARK P. VIGEN PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TF0200X	Forensic Psychologist	280	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	20559	OTHER	LA	BLUE CROSS/BLUE SHIELD
2	009755	OTHER	LA	VALUE OPTIONS

General Provider Information

NPI Number	:	1457329120
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK P. VIGEN PH.D.

Provider Business Mailing Address
First Line	:	3341 YOUREE DR STE 20A
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71105-2149
Country	:	US
Telephone Number	:	318-425-2000
Fax Number	:	318-424-2601

Provider Business Practice Location Address
First Line	:	3341 YOUREE DR STE 20A
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71105-2149
Country	:	US
Telephone Number	:	318-425-2000
Fax Number	:	318-424-2601

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/09/2006
Last Update Date	:	01/08/2020

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Directions to “ DR. MARK P. VIGEN PH.D.” Practice Location

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