Healthcare Provider Details

I. General information

NPI: 1609013721
Provider Name (Legal Business Name): LESTER COX MOREHEAD III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2009
Last Update Date: 03/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 KINGS HIGHWAY LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER
SHREVEPORT LA
71104-0000
US

IV. Provider business mailing address

1512 W KIRBY PL
SHREVEPORT LA
71103-3822
US

V. Phone/Fax

Practice location:
  • Phone: 318-675-5621
  • Fax:
Mailing address:
  • Phone: 318-675-7636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number203154
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: