Healthcare Provider Details

I. General information

NPI: 1700085727
Provider Name (Legal Business Name): BRYAN VEKOVIUS M.D. LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2007
Last Update Date: 08/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 ASHLEY RIDGE BLVD
SHREVEPORT LA
71106
US

IV. Provider business mailing address

450 ASHLEY RIDGE BLVD
SHREVEPORT LA
71106-7228
US

V. Phone/Fax

Practice location:
  • Phone: 318-675-3733
  • Fax: 318-675-3734
Mailing address:
  • Phone: 318-675-3733
  • Fax: 318-675-3734

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberLO 23263
License Number StateLA

VIII. Authorized Official

Name: BRYAN JOHANNES VEKOVIUS
Title or Position: DOCTOR
Credential: M.D.
Phone: 318-675-3733