Provider Demographics
NPI:1730101205
Name:TODD, JOHN RUCKER IV (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:RUCKER
Last Name:TODD
Suffix:IV
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1501 KINGS HWY
Mailing Address - Street 2:DEPARTMENT OF MEDICINE INF DISEASES
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4228
Mailing Address - Country:US
Mailing Address - Phone:318-675-5900
Mailing Address - Fax:318-675-5907
Practice Address - Street 1:1501 KINGS HWY
Practice Address - Street 2:DEPARTMENT OF MEDICINE INF DISEASES
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-675-5900
Practice Address - Fax:318-675-5907
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA06910R207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1380431Medicaid
LA54904F600Medicare ID - Type Unspecified
LA1380431Medicaid