Healthcare Provider Details

I. General information

NPI: 1235168311
Provider Name (Legal Business Name): ARK LA TEX FOOT & ANKLE SPECIALISTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2006
Last Update Date: 02/27/2020
Certification Date: 02/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

385 BERT KOUNS BLDG. 200
SHREVEPORT LA
71106-8158
US

IV. Provider business mailing address

385 BERT KOUNS BLDG. 200
SHREVEPORT LA
71106-8158
US

V. Phone/Fax

Practice location:
  • Phone: 318-687-8447
  • Fax: 318-687-9950
Mailing address:
  • Phone: 318-687-8447
  • Fax: 318-687-9950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPD067R / PD207R
License Number StateLA

VIII. Authorized Official

Name: GREGORY W. BRYAN
Title or Position: OWNER/MANAGER
Credential: DPM
Phone: 318-687-8447