MEDICARE: DANZELL FAMILY MEDICAL CLINIC

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	208D00000X	General Practice Physician	013603	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1134548175
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DANZELL FAMILY MEDICAL CLINIC

Provider Business Mailing Address
First Line	:	2500 KINGS HWY
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71103-3922
Country	:	US
Telephone Number	:	318-631-4030
Fax Number	:	318-631-4031

Provider Business Practice Location Address
First Line	:	2500 KINGS HWY
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71103-3922
Country	:	US
Telephone Number	:	318-631-4030
Fax Number	:	318-631-4031

Authorized Official
Title or Position	:	MEDICAL DOCTOR
Name	:	MR. JOHN DAVIS DANZELL JR.
Credential	:	M.D.
Telephone Number	:	318-631-4030

Provider Enumeration Date	:	04/07/2014
Last Update Date	:	04/07/2014

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Directions to “DANZELL FAMILY MEDICAL CLINIC ” Practice Location

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