Healthcare Provider Details

I. General information

NPI: 1336470574
Provider Name (Legal Business Name): WK PEDIATRIC GI SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2010
Last Update Date: 07/21/2021
Certification Date: 07/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2508 BERT KOUNS INDUSTRIAL LOOP SUITE 101
SHREVEPORT LA
71118-3133
US

IV. Provider business mailing address

2508 BERT KOUNS INDUSTRIAL LOOP SUITE 101
SHREVEPORT LA
71118-3133
US

V. Phone/Fax

Practice location:
  • Phone: 318-212-5858
  • Fax: 318-212-5877
Mailing address:
  • Phone: 318-212-5858
  • Fax: 318-212-5877

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: GREG J. GAVIN
Title or Position: NETWORK ADMINISTRATOR
Credential:
Phone: 318-424-4232