Healthcare Provider Details

I. General information

NPI: 1336152610
Provider Name (Legal Business Name): SUDARSHAN MANIKCHAND TANGA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 05/13/2025
Certification Date: 05/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8730 YOUREE DRIVE SUITE C
SHREVEPORT LA
71115
US

IV. Provider business mailing address

510 E STONER AVE
SHREVEPORT LA
71101-4243
US

V. Phone/Fax

Practice location:
  • Phone: 318-752-7960
  • Fax: 318-752-7880
Mailing address:
  • Phone: 318-221-8411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberMD.13420R
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberMD.13420R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: