Healthcare Provider Details

I. General information

NPI: 1982698023
Provider Name (Legal Business Name): CASSELL HUDSON DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 09/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2855 LONG LAKE DR
SHREVEPORT LA
71106
US

IV. Provider business mailing address

PO BOX 52834
SHREVEPORT LA
71135-2834
US

V. Phone/Fax

Practice location:
  • Phone: 318-797-4169
  • Fax: 318-797-4169
Mailing address:
  • Phone: 318-797-4169
  • Fax: 318-797-4169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPD149R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: