MEDICARE: ARK LA TEX FOOT & ANKLE SPECIALISTS, LLC

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	PD067R / PD207R	LA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	DE9683	OTHER	LA	RR MEDICARE

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	:	1235168311
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ARK LA TEX FOOT & ANKLE SPECIALISTS, LLC

Provider Business Mailing Address
First Line	:	385 BERT KOUNS
Second Line	:	BLDG. 200
City	:	SHREVEPORT
State	:	LA
Zip	:	71106-8158
Country	:	US
Telephone Number	:	318-687-8447
Fax Number	:	318-687-9950

Provider Business Practice Location Address
First Line	:	385 BERT KOUNS
Second Line	:	BLDG. 200
City	:	SHREVEPORT
State	:	LA
Zip	:	71106-8158
Country	:	US
Telephone Number	:	318-687-8447
Fax Number	:	318-687-9950

Authorized Official
Title or Position	:	OWNER/MANAGER
Name	:	GREGORY W. BRYAN
Credential	:	DPM
Telephone Number	:	318-687-8447

Provider Enumeration Date	:	07/01/2006
Last Update Date	:	02/27/2020

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