Healthcare Provider Details

I. General information

NPI: 1699778597
Provider Name (Legal Business Name): HUSAM HAIDAR SUKEREK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 HIGHLAND DR
MANY LA
71449-3718
US

IV. Provider business mailing address

210 HIGHLAND DR
MANY LA
71449-3718
US

V. Phone/Fax

Practice location:
  • Phone: 318-256-5722
  • Fax: 318-256-5774
Mailing address:
  • Phone: 318-256-5722
  • Fax: 318-256-5774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number13676R
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number13676R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: