Provider Demographics
NPI:1144297490
Name:FAKNER, REGINA (MD)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:FAKNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 FAIRFIELD AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4443
Mailing Address - Country:US
Mailing Address - Phone:318-226-4892
Mailing Address - Fax:318-227-4927
Practice Address - Street 1:1801 FAIRFIELD AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4443
Practice Address - Country:US
Practice Address - Phone:318-226-4892
Practice Address - Fax:318-227-4927
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA23952208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1667145Medicaid
LA5W419Medicare ID - Type Unspecified
LA1667145Medicaid