Healthcare Provider Details

I. General information

NPI: 1538130018
Provider Name (Legal Business Name): RANDALL P. BREWER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2006
Last Update Date: 10/04/2024
Certification Date: 10/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8731 PARK PLAZA DR
SHREVEPORT LA
71105
US

IV. Provider business mailing address

8731 PARK PLAZA DR
SHREVEPORT LA
71105-5682
US

V. Phone/Fax

Practice location:
  • Phone: 318-797-5848
  • Fax: 318-797-5844
Mailing address:
  • Phone: 318-797-5848
  • Fax: 318-797-5844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD.021953
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberMD.021953
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code2084P2900X
TaxonomyPain Medicine (Psychiatry & Neurology) Physician
License NumberMD.021953
License Number StateLA
# 4
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberMD.021953
License Number StateLA
# 5
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberMD.021953
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: