=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851359244
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MAXIMO C KIOK MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2006
-----------------------------------------------------
Last Update Date | 02/21/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 920 OLIVER RD # L
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71201-5702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-361-2161
-----------------------------------------------------
Fax | 318-812-6055
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 130 DESIARD ST STE 355
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71201-7363
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-998-3426
-----------------------------------------------------
Fax | 318-812-6603
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | 11562
-----------------------------------------------------
License Number State | ND
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | 15200R
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------