Healthcare Provider Details

I. General information

NPI: 1710364948
Provider Name (Legal Business Name): JEFFREY PEARSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2015
Last Update Date: 04/25/2022
Certification Date: 04/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 LINE AVE
SHREVEPORT LA
71101-4639
US

IV. Provider business mailing address

1534 ELIZABETH AVE STE 301
SHREVEPORT LA
71101-4531
US

V. Phone/Fax

Practice location:
  • Phone: 318-629-5001
  • Fax: 318-629-5020
Mailing address:
  • Phone: 318-629-5002
  • Fax: 318-629-6020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number325722
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number325722
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: