Healthcare Provider Details

I. General information

NPI: 1750697314
Provider Name (Legal Business Name): PLASTIC SURGERY OF SHREVEPORT, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2010
Last Update Date: 08/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1666 E BERT KOUNS LOOP STE 145
SHREVEPORT LA
71105-5714
US

IV. Provider business mailing address

1666 EAST BERT KOUNS INS LOOP STE 145
SHREVEPORT LA
71105-5718
US

V. Phone/Fax

Practice location:
  • Phone: 318-797-9199
  • Fax: 319-797-9193
Mailing address:
  • Phone: 318-797-9199
  • Fax: 319-797-9193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. PAUL M DAVIS
Title or Position: PRESIDENT
Credential: MD
Phone: 318-797-9199