Provider Demographics
NPI:1003863234
Name:HERBERT, ALLEN J (MD)
Entity Type:Individual
Prefix:DR
First Name:ALLEN
Middle Name:J
Last Name:HERBERT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1768
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71166-1768
Mailing Address - Country:US
Mailing Address - Phone:318-677-7450
Mailing Address - Fax:318-425-5815
Practice Address - Street 1:411 E VAUGHN AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-5972
Practice Address - Country:US
Practice Address - Phone:318-255-7474
Practice Address - Fax:318-425-2335
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-31
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LAMD 010285207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1126403Medicaid
LA720972556OtherTRICARE
LAB60462Medicare UPIN
LA1126403Medicaid