Healthcare Provider Details

I. General information

NPI: 1982676771
Provider Name (Legal Business Name): SHREVEPORT ENDOSCOPY CENTER, A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2006
Last Update Date: 08/12/2022
Certification Date: 08/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3217 MABEL ST
SHREVEPORT LA
71103-4022
US

IV. Provider business mailing address

3217 MABEL ST
SHREVEPORT LA
71103-4022
US

V. Phone/Fax

Practice location:
  • Phone: 318-631-0072
  • Fax: 318-213-4979
Mailing address:
  • Phone: 318-631-0072
  • Fax: 318-213-4979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0800X
TaxonomyEndoscopy Clinic/Center
License Number50
License Number StateLA

VIII. Authorized Official

Name: DR. SATHYA JAGANMOHAN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 318-631-0072