Healthcare Provider Details

I. General information

NPI: 1811952690
Provider Name (Legal Business Name): SHREVEPORT GERIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 MARGARET PL
SHREVEPORT LA
71101
US

IV. Provider business mailing address

824 DUDLEY DR
SHREVEPORT LA
71104-4814
US

V. Phone/Fax

Practice location:
  • Phone: 318-222-8187
  • Fax:
Mailing address:
  • Phone: 318-222-8187
  • Fax: 318-227-0437

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number StateLA

VIII. Authorized Official

Name: MR. LAWRENCE J DREXLER
Title or Position: OWNER PRESIDENT
Credential: MD
Phone: 318-222-8187