Healthcare Provider Details

I. General information

NPI: 1972007151
Provider Name (Legal Business Name): HARRISON D MARTIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2018
Last Update Date: 10/10/2024
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E PRESTON AVE
SHREVEPORT LA
71105-2704
US

IV. Provider business mailing address

1000 E PRESTON AVE
SHREVEPORT LA
71105-2704
US

V. Phone/Fax

Practice location:
  • Phone: 318-841-9532
  • Fax:
Mailing address:
  • Phone: 318-841-9532
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number340915
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: