Healthcare Provider Details

I. General information

NPI: 1154693968
Provider Name (Legal Business Name): FREDERICK JACQUES HALL D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2012
Last Update Date: 02/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 E STONER AVE
SHREVEPORT LA
71101-4243
US

IV. Provider business mailing address

510 E STONER AVE
SHREVEPORT LA
71101-4243
US

V. Phone/Fax

Practice location:
  • Phone: 678-640-5685
  • Fax:
Mailing address:
  • Phone: 678-640-5685
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberPOD000612
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberPOD000612
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: