Healthcare Provider Details

I. General information

NPI: 1548264211
Provider Name (Legal Business Name): KURT THOMAS GROZINGER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 04/12/2022
Certification Date: 04/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2105 AIRLINE DR
BOSSIER CITY LA
71111-3105
US

IV. Provider business mailing address

1512 W KIRBY PL
SHREVEPORT LA
71103-3822
US

V. Phone/Fax

Practice location:
  • Phone: 318-741-6078
  • Fax:
Mailing address:
  • Phone: 318-626-0287
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number05413R
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number05413R
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD.05413R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: