Healthcare Provider Details

I. General information

NPI: 1801838966
Provider Name (Legal Business Name): BRENDA L MCINTYRE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 01/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 N TRENTON ST
RUSTON LA
71270-3840
US

IV. Provider business mailing address

PO BOX 13082
RUSTON LA
71273-3082
US

V. Phone/Fax

Practice location:
  • Phone: 318-255-4112
  • Fax: 318-251-8727
Mailing address:
  • Phone: 318-255-4112
  • Fax: 318-251-8727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD00042179
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD202561
License Number StateLA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1343072
Identifier TypeMEDICAID
Identifier StateLA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: