Healthcare Provider Details

I. General information

NPI: 1073517975
Provider Name (Legal Business Name): RUSSELL D BURLISON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2005
Last Update Date: 10/17/2025
Certification Date: 10/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1455 E BERT KOUN LOOP
SHREVEPORT LA
71105-5634
US

IV. Provider business mailing address

1455 E BERT KOUNS LOOP
SHREVEPORT LA
71105-5634
US

V. Phone/Fax

Practice location:
  • Phone: 318-798-4400
  • Fax: 318-798-4525
Mailing address:
  • Phone: 318-798-4400
  • Fax: 318-798-4525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number023583
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: