Healthcare Provider Details

I. General information

NPI: 1942120944
Provider Name (Legal Business Name): DONOVAN LANDRY BSRS, (R)(CT)
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2026
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

524 DR MICHAEL DEBAKEY DR
LAKE CHARLES LA
70601-5725
US

IV. Provider business mailing address

2400 FENIMORE LOOP
WESTLAKE LA
70669-5400
US

V. Phone/Fax

Practice location:
  • Phone: 337-436-2511
  • Fax:
Mailing address:
  • Phone: 337-660-7601
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471C3401X
TaxonomyComputed Tomography Radiologic Technologist
License Number12994
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: