Healthcare Provider Details

I. General information

NPI: 1730200866
Provider Name (Legal Business Name): JAY PHILIP FAKIER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 03/01/2024
Certification Date: 03/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 E STONER AVE
SHREVEPORT LA
71101-4243
US

IV. Provider business mailing address

436 RAILSBACK ST
SHREVEPORT LA
71106-7726
US

V. Phone/Fax

Practice location:
  • Phone: 985-859-9669
  • Fax:
Mailing address:
  • Phone: 985-859-9669
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number201278
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: