Healthcare Provider Details

I. General information

NPI: 1033381520
Provider Name (Legal Business Name): HOPKINS DERMATOLOGY APMC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2008
Last Update Date: 06/30/2023
Certification Date: 06/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2509 BROADMOOR BLVD SUITE A
MONROE LA
71201-2987
US

IV. Provider business mailing address

2509 BROADMOOR BLVD SUITE A
MONROE LA
71201-2987
US

V. Phone/Fax

Practice location:
  • Phone: 318-325-0600
  • Fax: 318-325-0890
Mailing address:
  • Phone: 318-325-0600
  • Fax: 318-325-0890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberMD.021601
License Number StateLA

VIII. Authorized Official

Name: MRS. LISA CANOY SHORE
Title or Position: OFFICE MANAGER
Credential:
Phone: 318-325-0600