MEDICARE: PRISCILLA IHENACHO MD

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	207R00000X	Internal Medicine Physician	46868	OK
2	207R00000X	Internal Medicine Physician	W3958	TX
3	207R00000X	Internal Medicine Physician	341726	LA

General Provider Information

NPI Number	:	1518532886
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PRISCILLA IHENACHO MD

Provider Business Mailing Address
First Line	:	205 HOLIDAY BLVD
Second Line	:	SUITE 100 PMB
City	:	SHREVEPORT
State	:	LA
Zip	:	71103-4228
Country	:	US
Telephone Number	:	945-941-0704
Fax Number	:	888-338-1461

Provider Business Practice Location Address
First Line	:	205 HOLIDAY BLVD
Second Line	:	SUITE 100
City	:	SHREVEPORT
State	:	LA
Zip	:	71103-4228
Country	:	US
Telephone Number	:	945-941-0704
Fax Number	:	888-338-1461

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/20/2021
Last Update Date	:	04/14/2026

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