Healthcare Provider Details

I. General information

NPI: 1174013874
Provider Name (Legal Business Name): PATRIC DARVIE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2018
Last Update Date: 12/28/2022
Certification Date: 12/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3775 YOUREE DR
SHREVEPORT LA
71105-2133
US

IV. Provider business mailing address

1501 KINGS HWY
SHREVEPORT LA
71103-4228
US

V. Phone/Fax

Practice location:
  • Phone: 318-562-3366
  • Fax:
Mailing address:
  • Phone: 318-626-4092
  • Fax: 318-675-7950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number333276
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: