Healthcare Provider Details

I. General information

NPI: 1619987690
Provider Name (Legal Business Name): ROY BRASWELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4864 JACKSON ST DEPARTMENT OF EMERGENCY MEDICAL SERVICES
MONROE LA
71202-6400
US

IV. Provider business mailing address

1501 KINGS HWY MANAGED CARE
SHREVEPORT LA
71103-4228
US

V. Phone/Fax

Practice location:
  • Phone: 318-675-7737
  • Fax: 318-675-5666
Mailing address:
  • Phone: 318-675-7737
  • Fax: 318-675-5666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number06140R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: