Healthcare Provider Details

I. General information

NPI: 1467526178
Provider Name (Legal Business Name): RAYMOND EDWARD DENNIE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 11/09/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2724 GREENWOOD RD
SHREVEPORT LA
71109-4635
US

IV. Provider business mailing address

6121 FERN AVE 79 PIERREMONT PLACE
SHREVEPORT LA
71105-4155
US

V. Phone/Fax

Practice location:
  • Phone: 318-212-4248
  • Fax: 318-212-4545
Mailing address:
  • Phone: 318-797-1356
  • Fax: 318-212-4545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number4185R
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License NumberAD8213326 DEA
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberMD04185R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: