Healthcare Provider Details

I. General information

NPI: 1245852698
Provider Name (Legal Business Name): MOSTAFA HOTAIT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2020
Last Update Date: 08/26/2024
Certification Date: 08/26/2024
Deactivation Date: 01/11/2022
Reactivation Date: 02/15/2022

III. Provider practice location address

1541 KINGS HWY
SHREVEPORT LA
71103-4228
US

IV. Provider business mailing address

1541 KINGS HWY ATTN: PAYOR CREDENTIALING
SHREVEPORT LA
71103-4228
US

V. Phone/Fax

Practice location:
  • Phone: 318-626-0000
  • Fax:
Mailing address:
  • Phone: 318-626-0287
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number332761
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code2084E0001X
TaxonomyEpilepsy Physician
License Number332761
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: