Healthcare Provider Details

I. General information

NPI: 1740357722
Provider Name (Legal Business Name): JOHN ERIC BICKNELL SR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 11/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7925 YOUREE DRIVE SUITE 280A
SHREVEPORT LA
71105
US

IV. Provider business mailing address

7925 YOUREE DRIVE SUITE 280A
SHREVEPORT LA
71105
US

V. Phone/Fax

Practice location:
  • Phone: 318-798-6833
  • Fax: 318-798-6835
Mailing address:
  • Phone: 318-798-6833
  • Fax: 318-798-6835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number016810
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code204R00000X
TaxonomyElectrodiagnostic Medicine Physician
License Number016810
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: