Healthcare Provider Details

I. General information

NPI: 1285674820
Provider Name (Legal Business Name): BRYAN JOHANNES VEKOVIUS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 05/20/2020
Certification Date: 05/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 ASHLEY RIDGE BLVD
SHREVEPORT LA
71106-7228
US

IV. Provider business mailing address

450 ASHLEY RIDGE BLVD
SHREVEPORT LA
71106-7228
US

V. Phone/Fax

Practice location:
  • Phone: 318-375-3733
  • Fax: 318-675-3734
Mailing address:
  • Phone: 318-675-3733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207WX0109X
TaxonomyNeuro-ophthalmology Physician
License NumberL023263
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code207WX0200X
TaxonomyOphthalmic Plastic and Reconstructive Surgery Physician
License NumberL023263
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberL023263
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: