Provider Demographics
NPI:1184033854
Name:ARKLATEX FERTILITY AND REPRODUCTIVE MEDICINE
Entity Type:Organization
Organization Name:ARKLATEX FERTILITY AND REPRODUCTIVE MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:VANDERMOLEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-841-5800
Mailing Address - Street 1:2401 GREENWOOD RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4010
Mailing Address - Country:US
Mailing Address - Phone:318-841-5800
Mailing Address - Fax:318-841-5817
Practice Address - Street 1:2401 GREENWOOD RD
Practice Address - Street 2:SUITE A
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4010
Practice Address - Country:US
Practice Address - Phone:318-841-5800
Practice Address - Fax:318-841-5817
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-07
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QA0006X
LAAP0799363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA0006XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Fertility FacilityGroup - Single Specialty
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Single Specialty