Healthcare Provider Details

I. General information

NPI: 1598077323
Provider Name (Legal Business Name): DR. VIRGINIA HOMZA CARTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2010
Last Update Date: 06/21/2021
Certification Date: 06/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 OLIVE ST
SHREVEPORT LA
71104
US

IV. Provider business mailing address

WK PEDIATRIC HEALTH & WELLNESS 909 OLIVE STREET
SHREVEPORT LA
71104-2103
US

V. Phone/Fax

Practice location:
  • Phone: 318-698-3291
  • Fax: 318-698-3293
Mailing address:
  • Phone: 318-698-3291
  • Fax: 318-698-3293

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberT-2322
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD.206164
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: