Provider Demographics
NPI:1073565370
Name:BICKHAM, EWELL III
Entity Type:Individual
Prefix:DR
First Name:EWELL
Middle Name:
Last Name:BICKHAM
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 368
Mailing Address - Street 2:
Mailing Address - City:SAINT FRANCISVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70775-0368
Mailing Address - Country:US
Mailing Address - Phone:225-635-3811
Mailing Address - Fax:225-635-2435
Practice Address - Street 1:5266 COMMERCE ST
Practice Address - Street 2:
Practice Address - City:SAINT FRANCISVILLE
Practice Address - State:LA
Practice Address - Zip Code:70775-4409
Practice Address - Country:US
Practice Address - Phone:225-635-2436
Practice Address - Fax:225-635-2435
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA022207207Q00000X
LAMD.022207207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1490342Medicaid
LA5H293Medicare ID - Type Unspecified
LAH15081Medicare UPIN