1902950363 NPI number — RICHARD A AYCOCK II MD

Table of content: RICHARD A AYCOCK II MD (NPI 1902950363)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902950363 NPI number — RICHARD A AYCOCK II MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AYCOCK
Provider First Name:
RICHARD
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
II
Provider Credential Text:
MD
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:
1902950363
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 32600
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:
71130-2600
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-212-4877
Provider Business Mailing Address Fax Number:
318-212-4192

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2510 BERT KOUNS INDISTRIAL LOOP
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:
71118
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-212-5500
Provider Business Practice Location Address Fax Number:
318-212-5358
Provider Enumeration Date:
01/23/2007

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: 207P00000X , with the licence number:  09978R , 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: 1686573 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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