Provider Demographics
NPI:1083606040
Name:BRANDHURST, ROY (MD)
Entity Type:Individual
Prefix:
First Name:ROY
Middle Name:
Last Name:BRANDHURST
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:PO BOX 32600
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71130-2600
Mailing Address - Country:US
Mailing Address - Phone:318-212-4877
Mailing Address - Fax:318-212-4192
Practice Address - Street 1:8001 YOUREE DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71115-2302
Practice Address - Country:US
Practice Address - Phone:318-212-3500
Practice Address - Fax:318-212-3505
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA022554207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1490431Medicaid
LA1490431Medicaid
5Y326Medicare ID - Type Unspecified