Healthcare Provider Details

I. General information

NPI: 1285635540
Provider Name (Legal Business Name): LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER VIRAL DISEASE CLINI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6670 SAINT VINCENT AVE
SHREVEPORT LA
71106-2638
US

IV. Provider business mailing address

1821 BAYOU DR
SHREVEPORT LA
71105-3403
US

V. Phone/Fax

Practice location:
  • Phone: 318-862-9986
  • Fax:
Mailing address:
  • Phone: 318-865-2578
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateLA

VIII. Authorized Official

Name: DR. ROBERT PENN
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 318-798-5930