Healthcare Provider Details

I. General information

NPI: 1316418288
Provider Name (Legal Business Name): DRG MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2018
Last Update Date: 10/26/2020
Certification Date: 10/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1549 ELIZABETH AVE
SHREVEPORT LA
71101-4501
US

IV. Provider business mailing address

1549 ELIZABETH AVE
SHREVEPORT LA
71101-4501
US

V. Phone/Fax

Practice location:
  • Phone: 318-918-0058
  • Fax:
Mailing address:
  • Phone: 318-918-0058
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. WILLIAM LEE GIBSON JR.
Title or Position: MANAGER
Credential: MD
Phone: 318-918-0058