Healthcare Provider Details

I. General information

NPI: 1366548885
Provider Name (Legal Business Name): CREIGHTON CHANDLER JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 01/06/2020
Certification Date: 01/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 OLIVER RD # A
MONROE LA
71201-5702
US

IV. Provider business mailing address

130 DESIARD ST STE 355
MONROE LA
71201-7363
US

V. Phone/Fax

Practice location:
  • Phone: 318-361-2136
  • Fax: 318-812-6338
Mailing address:
  • Phone: 318-807-7875
  • Fax: 318-812-6603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number011443
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: