Healthcare Provider Details

I. General information

NPI: 1538109988
Provider Name (Legal Business Name): HENRY J GOOLSBY III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2002 W WALNUT ST STE 2
LAKE CHARLES LA
70601-5690
US

IV. Provider business mailing address

501 DR MICHAEL DEBAKEY DR
LAKE CHARLES LA
70601-5724
US

V. Phone/Fax

Practice location:
  • Phone: 337-312-8234
  • Fax: 337-312-8411
Mailing address:
  • Phone: 337-312-8360
  • Fax: 337-312-6711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number201907
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberMD0000024339
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: