Healthcare Provider Details

I. General information

NPI: 1003860180
Provider Name (Legal Business Name): EMMANUEL WITHERSPOON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2006
Last Update Date: 08/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 W BOUNDARY AVE
WINNFIELD LA
71483-3427
US

IV. Provider business mailing address

200 CORPORATE BLVD SUITE 201
LAFAYETTE LA
70508-3870
US

V. Phone/Fax

Practice location:
  • Phone: 318-442-2859
  • Fax:
Mailing address:
  • Phone: 800-893-9698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number07878R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: