Healthcare Provider Details

I. General information

NPI: 1265994032
Provider Name (Legal Business Name): MARSHALL J. BYUN-ANDERSEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2019
Last Update Date: 01/10/2023
Certification Date: 12/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1541 KINGS HIGHWAY FAMILY MEDICINE
SHREVEPORT LA
71130-3932
US

IV. Provider business mailing address

1541 KINGS HIGHWAY FAMILY MEDICINE
SHREVEPORT LA
71130-3932
US

V. Phone/Fax

Practice location:
  • Phone: 318-626-0014
  • Fax:
Mailing address:
  • Phone: 318-626-0014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number330641
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number330641
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: