Healthcare Provider Details

I. General information

NPI: 1962579052
Provider Name (Legal Business Name): GLEN D HURLSTON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 W FERTITTA BLVD
LEESVILLE LA
71446-4649
US

IV. Provider business mailing address

PO BOX 54346
NEW ORLEANS LA
70154-4346
US

V. Phone/Fax

Practice location:
  • Phone: 337-475-9927
  • Fax: 337-475-9989
Mailing address:
  • Phone: 337-475-9927
  • Fax: 337-475-9989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number022284
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: