MEDICARE: SOUTHSIDE FOOT CLINIC OF SHREVEPORT, INC. A PROFESSIONAL CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213ES0103X	Foot & Ankle Surgery Podiatrist	5B496	LA

General Provider Information

NPI Number	:	1033111240
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHSIDE FOOT CLINIC OF SHREVEPORT, INC. A PROFESSIONAL CORPORATION

Provider Business Mailing Address
First Line	:	9308 MANSFIELD RD
Second Line	:	STE 100
City	:	SHREVEPORT
State	:	LA
Zip	:	71118-3134
Country	:	US
Telephone Number	:	318-687-6266
Fax Number	:	318-683-1023

Provider Business Practice Location Address
First Line	:	9308 MANSFIELD RD
Second Line	:	STE 100
City	:	SHREVEPORT
State	:	LA
Zip	:	71118-3134
Country	:	US
Telephone Number	:	318-687-6266
Fax Number	:	318-683-1023

Authorized Official
Title or Position	:	PHYSICIAN/ADMINISTRATOR
Name	:	MR. RICHARD TAYLOR HAVENS
Credential	:	D.P.M.
Telephone Number	:	318-687-6266

Provider Enumeration Date	:	06/01/2005
Last Update Date	:	12/29/2025

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