Healthcare Provider Details

I. General information

NPI: 1003202946
Provider Name (Legal Business Name): RAJIV DODDAMANI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2015
Last Update Date: 01/09/2026
Certification Date: 01/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4864 JACKSON ST
MONROE LA
71202-6400
US

IV. Provider business mailing address

1541 KINGS HWY ATTN: PAYOR CREDENTIALING
SHREVEPORT LA
71103-4228
US

V. Phone/Fax

Practice location:
  • Phone: 318-330-7000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number310930
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number310930
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: