MEDICARE: SHREVEPORT EYE 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	207W00000X	Ophthalmology Physician	MD.024870	LA

General Provider Information

NPI Number	:	1528587441
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHREVEPORT EYE SPECIALISTS, LLC

Provider Business Mailing Address
First Line	:	1801 FAIRFIELD AVE STE 207
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71101-4460
Country	:	US
Telephone Number	:	318-703-5655
Fax Number	:	318-606-5470

Provider Business Practice Location Address
First Line	:	1801 FAIRFIELD AVE STE 207
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71101-4460
Country	:	US
Telephone Number	:	318-489-5949
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. RUSSELL H VAN NORMAN
Credential	:	MD
Telephone Number	:	318-703-5655

Provider Enumeration Date	:	09/12/2017
Last Update Date	:	01/25/2018

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