Provider Demographics
NPI:1649304122
Name:DESOTO PHYSICIANS & SURGEONS CLINIC
Entity type:Organization
Organization Name:DESOTO PHYSICIANS & SURGEONS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CLINICS PHYS SRCS
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:L
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-872-4610
Mailing Address - Street 1:119 JEFFERSON ST
Mailing Address - Street 2:PO BOX 739
Mailing Address - City:MANSFIELD
Mailing Address - State:LA
Mailing Address - Zip Code:71052-2601
Mailing Address - Country:US
Mailing Address - Phone:318-872-5810
Mailing Address - Fax:318-872-2763
Practice Address - Street 1:119 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:LA
Practice Address - Zip Code:71052-2601
Practice Address - Country:US
Practice Address - Phone:318-872-5810
Practice Address - Fax:318-872-2763
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA025688208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5DD95Medicare PIN