Provider Demographics
NPI:1114022175
Name:PICKERING, MICHAEL DAVID (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DAVID
Last Name:PICKERING
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5848 LINE AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-1532
Mailing Address - Country:US
Mailing Address - Phone:318-865-0017
Mailing Address - Fax:318-868-4738
Practice Address - Street 1:5848 LINE AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-1532
Practice Address - Country:US
Practice Address - Phone:318-865-0017
Practice Address - Fax:318-868-4738
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA963-247T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1362549Medicaid
LA2504BOtherBCBS
LA1362549Medicaid
LAT69529Medicare UPIN