Healthcare Provider Details

I. General information

NPI: 1942414552
Provider Name (Legal Business Name): JEFFREY T OVERDYKE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 11/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2508 BERT KOUNS LOOP SUITE 303
SHREVEPORT LA
71118-3133
US

IV. Provider business mailing address

1202 LOUISIANA AVE
SHREVEPORT LA
71101-3910
US

V. Phone/Fax

Practice location:
  • Phone: 318-212-5850
  • Fax: 318-212-5855
Mailing address:
  • Phone: 318-212-8574
  • Fax: 318-212-4153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number203179
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: