Provider Demographics
NPI:1043292600
Name:HARGRAVE, KEVIN RENEE (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:RENEE
Last Name:HARGRAVE
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 1:136 HOSPITAL DR. STE 100
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503
Mailing Address - Country:US
Mailing Address - Phone:337-235-4554
Mailing Address - Fax:337-235-4556
Practice Address - Street 1:136 HOSPITAL DR. STE 100
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503
Practice Address - Country:US
Practice Address - Phone:337-289-8282
Practice Address - Fax:337-289-8283
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-18
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA13877R174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAH08094Medicare UPIN