Healthcare Provider Details

I. General information

NPI: 1003863234
Provider Name (Legal Business Name): ALLEN J HERBERT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 11/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 E VAUGHN AVE SUITE 203
RUSTON LA
71270-5972
US

IV. Provider business mailing address

PO BOX 1768
SHREVEPORT LA
71166-1768
US

V. Phone/Fax

Practice location:
  • Phone: 318-255-7474
  • Fax: 318-425-2335
Mailing address:
  • Phone: 318-677-7450
  • Fax: 318-425-5815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD 010285
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: