Provider Demographics
NPI:1104034867
Name:OB GYN ASSOCIATES OF SHREVEPORT
Entity Type:Organization
Organization Name:OB GYN ASSOCIATES OF SHREVEPORT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:WALTER
Authorized Official - Last Name:WATERFALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-797-7941
Mailing Address - Street 1:7941 YOUREE DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5538
Mailing Address - Country:US
Mailing Address - Phone:318-797-7941
Mailing Address - Fax:318-797-7991
Practice Address - Street 1:7941 YOUREE DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5538
Practice Address - Country:US
Practice Address - Phone:318-797-7941
Practice Address - Fax:318-797-7991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2019-02-04
Deactivation Date:2017-10-04
Deactivation Code:
Reactivation Date:2019-02-04
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5B256Medicare ID - Type UnspecifiedMEDICARE GOUP PROVIDER ID