Healthcare Provider Details

I. General information

NPI: 1780093831
Provider Name (Legal Business Name): ABHISHEK KUMAR JAISWAL MBBS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2014
Last Update Date: 12/09/2024
Certification Date: 12/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1811 E BERT KOUNS INDUSTRIAL LOOP STE 210
SHREVEPORT LA
71105-5740
US

IV. Provider business mailing address

1811 E BERT KOUNS INDUSTRIAL LOOP STE 210
SHREVEPORT LA
71105-5740
US

V. Phone/Fax

Practice location:
  • Phone: 318-212-3858
  • Fax: 318-212-3958
Mailing address:
  • Phone: 318-212-3858
  • Fax: 318-212-3958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number29614
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number342726
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: