Healthcare Provider Details

I. General information

NPI: 1063717841
Provider Name (Legal Business Name): PRACTICEMD, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2011
Last Update Date: 01/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

242 LYNBROOK BLVD
SHREVEPORT LA
71106-6548
US

IV. Provider business mailing address

PO BOX 6657
SHREVEPORT LA
71136-6657
US

V. Phone/Fax

Practice location:
  • Phone: 318-841-4312
  • Fax: 318-841-4342
Mailing address:
  • Phone: 318-841-4312
  • Fax: 318-841-4342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: MR. MIKE BYRD
Title or Position: C.O.O.
Credential:
Phone: 318-841-4312