Healthcare Provider Details

I. General information

NPI: 1487066296
Provider Name (Legal Business Name): ALFRED W. HATHORN JR., M.D. APMC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2014
Last Update Date: 05/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2120 BERT KOUN LOOP SUITE # L
SHREVEPORT LA
71118-3351
US

IV. Provider business mailing address

2120 BERT KOUN LOOP SUITE # L
SHREVEPORT LA
71118-3351
US

V. Phone/Fax

Practice location:
  • Phone: 318-686-8197
  • Fax: 318-688-5962
Mailing address:
  • Phone: 318-686-8197
  • Fax: 318-688-5962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number011400
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAP06110
License Number StateLA

VIII. Authorized Official

Name: RUTH A HATHORN
Title or Position: OFFICE MANAGER
Credential:
Phone: 318-686-8197