Healthcare Provider Details

I. General information

NPI: 1588195911
Provider Name (Legal Business Name): AMMOURA MOHAMMED IBRAHIM M.B.CH.B
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2017
Last Update Date: 11/01/2024
Certification Date: 11/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1541 KINGS HWY
SHREVEPORT LA
71103-4228
US

IV. Provider business mailing address

1541 KINGS HWY ATTN: PAYOR CREDENTIALING
SHREVEPORT LA
71103-4228
US

V. Phone/Fax

Practice location:
  • Phone: 318-626-0000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZH0000X
TaxonomyHematology (Pathology) Physician
License Number342369
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code207ZP0007X
TaxonomyMolecular Genetic Pathology (Pathology) Physician
License Number342369
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number342369
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: