1043359839 NPI number — DESOTO REGIONAL FAMILY MEDICINE

Table of content: (NPI 1043359839)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043359839 NPI number — DESOTO REGIONAL FAMILY MEDICINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DESOTO REGIONAL FAMILY MEDICINE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043359839
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
130 JEFFERSON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANSFIELD
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71052-2602
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-872-2700
Provider Business Mailing Address Fax Number:
318-872-6214

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
130 JEFFERSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANSFIELD
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71052-2602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-872-2700
Provider Business Practice Location Address Fax Number:
318-872-6214
Provider Enumeration Date:
02/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DEUTSCH
Authorized Official First Name:
HALLIE
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING SPECIALIST
Authorized Official Telephone Number:
318-871-3101

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: CN5547 . This is a "RR MEDICARE" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: 1948357 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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