Healthcare Provider Details

I. General information

NPI: 1104846989
Provider Name (Legal Business Name): KEVIN MARK SITTIG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 08/26/2020
Certification Date: 08/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1541 KINGS HWY DEPT OF
SHREVEPORT LA
71103-4228
US

IV. Provider business mailing address

1512 W KIRBY PL
SHREVEPORT LA
71103-3822
US

V. Phone/Fax

Practice location:
  • Phone: 318-813-2655
  • Fax: 318-675-4689
Mailing address:
  • Phone: 318-626-0287
  • Fax: 318-629-4808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number017190
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number017190
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number017190
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: