1891799607 NPI number — DR. BENNY M POPWELL M

Table of content: DR. BENNY M POPWELL M (NPI 1891799607)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891799607 NPI number — DR. BENNY M POPWELL M

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POPWELL
Provider First Name:
BENNY
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1891799607
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/10/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1455 E BERT KOUNS LOOP
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHREVEPORT
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71105-5634
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-798-4400
Provider Business Mailing Address Fax Number:
318-798-4621

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1455 E BERT KOUN LOOP STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71105-5634
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-681-4606
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  014125 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P00313369 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: 050825102 . This is a "TEXAS MEDICAID" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1053315846 . This is a "GROUP NPI NUMBER" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: 1314293 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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