Healthcare Provider Details

I. General information

NPI: 1679716799
Provider Name (Legal Business Name): NITIN WALYAT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2009
Last Update Date: 03/15/2023
Certification Date: 03/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 KINGS HWY
SHREVEPORT LA
71103
US

IV. Provider business mailing address

1501 KINGS HWY ATTN: LEISA OGLESBY (RM. 1-201)
SHREVEPORT LA
71103-4228
US

V. Phone/Fax

Practice location:
  • Phone: 318-675-4881
  • Fax: 318-675-5069
Mailing address:
  • Phone: 318-675-4881
  • Fax: 318-675-5069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberR2499
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD.205325
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberR2499
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberMD.205325
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: