Healthcare Provider Details

I. General information

NPI: 1285643908
Provider Name (Legal Business Name): RICHARD TAYLOR HAVENS DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 08/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9308 MANSFIELD RD STE 100
SHREVEPORT LA
71118-3134
US

IV. Provider business mailing address

9308 MANSFIELD RD STE 100
SHREVEPORT LA
71118-3160
US

V. Phone/Fax

Practice location:
  • Phone: 318-687-6266
  • Fax: 318-683-1023
Mailing address:
  • Phone: 318-687-6266
  • Fax: 318-683-1023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPDR073R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: