Provider Demographics
NPI:1649268590
Name:MATRIANO LIM, ALLAN S (MD)
Entity type:Individual
Prefix:
First Name:ALLAN
Middle Name:S
Last Name:MATRIANO LIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8001 YOUREE DR
Mailing Address - Street 2:SUITE 720
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71115-2302
Mailing Address - Country:US
Mailing Address - Phone:318-798-9881
Mailing Address - Fax:318-798-9979
Practice Address - Street 1:8001 YOUREE DR
Practice Address - Street 2:SUITE 720
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71115-2302
Practice Address - Country:US
Practice Address - Phone:318-798-9881
Practice Address - Fax:318-798-9979
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-13
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA021617207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1682411Medicaid
LAG31138Medicare UPIN
LA1682411Medicaid