Provider Demographics
NPI:1073585477
Name:UTTER, PHILIP ANDREW (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:ANDREW
Last Name:UTTER
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 1:1500 LINE AVENUE
Mailing Address - Street 2:STE 200
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101
Mailing Address - Country:US
Mailing Address - Phone:318-629-5555
Mailing Address - Fax:318-629-5556
Practice Address - Street 1:1500 LINE AVENUE
Practice Address - Street 2:STE 200
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101
Practice Address - Country:US
Practice Address - Phone:318-629-5555
Practice Address - Fax:318-629-5556
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2009-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN44123207T00000X
OH91820207T00000X
LA202784207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN200821100Medicaid
MN110229121Medicare ID - Type UnspecifiedRAILROAD
MN200821100Medicaid
H50962Medicare UPIN
LA4M112B103Medicare PIN
MN140000254Medicare PIN