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General NPI Number Information
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NPI Number | 1316228984
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Entity Type | Organization
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Legal Business Name | CHOICE PEDIATRICS, LLC
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Dates
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Enumeration Date | 09/08/2011
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Last Update Date | 12/29/2011
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Provider Practice Location Address
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Address Line | 6930 FERN AVE SUITE 150
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City | SHREVEPORT
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State | LA
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Zip | 71105-4100
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Country | US
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Telephone | 318-290-3673
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Fax | 318-290-3672
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Provider Business Mailing Address
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Address Line | PO BOX 5866
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City | SHREVEPORT
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State | LA
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Zip | 71135-5866
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Country | US
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Telephone | 318-290-3673
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Fax | 318-290-3672
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Authorized Official
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Title or Position | OWNER
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Name | DR. OLABODE O DESALU
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Credential | MD
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Telephone | 318-290-3673
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 15345R
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License Number State | LA
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