Healthcare Provider Details

I. General information

NPI: 1164411815
Provider Name (Legal Business Name): KHALDOUN SOUDAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2005
Last Update Date: 07/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2220 WORLEY DR
ALEXANDRIA LA
71301-3600
US

IV. Provider business mailing address

2220 WORLEY DR
ALEXANDRIA LA
71301-3600
US

V. Phone/Fax

Practice location:
  • Phone: 318-704-0001
  • Fax: 318-704-0002
Mailing address:
  • Phone: 318-704-0001
  • Fax: 318-704-0002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number204504
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: