Healthcare Provider Details

I. General information

NPI: 1871751057
Provider Name (Legal Business Name): LAURA ASHLEY MITCHAM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2008
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 E STONER AVE
SHREVEPORT LA
71101-4243
US

IV. Provider business mailing address

1305 BIENVILLE AVE
RUSTON LA
71270-5203
US

V. Phone/Fax

Practice location:
  • Phone: 504-338-2868
  • Fax:
Mailing address:
  • Phone: 504-338-2868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number204145
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number204145
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: