Healthcare Provider Details

I. General information

NPI: 1568549574
Provider Name (Legal Business Name): CARY H MIELKE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 08/26/2024
Certification Date: 08/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 SAMFORD AVE
SHREVEPORT LA
71103
US

IV. Provider business mailing address

1541 KINGS HWY
SHREVEPORT LA
71103-4228
US

V. Phone/Fax

Practice location:
  • Phone: 318-226-3306
  • Fax: 318-226-3319
Mailing address:
  • Phone: 318-626-0177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number32198
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207XP3100X
TaxonomyPediatric Orthopaedic Surgery Physician
License Number32198
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number309011
License Number StateLA
# 4
Primary TaxonomyN
Taxonomy Code207XP3100X
TaxonomyPediatric Orthopaedic Surgery Physician
License Number309011
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: