Provider Demographics
NPI:1235168311
Name:ARK LA TEX FOOT & ANKLE SPECIALISTS, LLC
Entity Type:Organization
Organization Name:ARK LA TEX FOOT & ANKLE SPECIALISTS, LLC
Other - Org Name:ARK LA TEX FOOT SPECIALISTS, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:W
Authorized Official - Last Name:BRYAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:318-687-8447
Mailing Address - Street 1:385 BERT KOUNS
Mailing Address - Street 2:BLDG. 200
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-8158
Mailing Address - Country:US
Mailing Address - Phone:318-687-8447
Mailing Address - Fax:318-687-9950
Practice Address - Street 1:385 BERT KOUNS
Practice Address - Street 2:BLDG. 200
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-8158
Practice Address - Country:US
Practice Address - Phone:318-687-8447
Practice Address - Fax:318-687-9950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPD067R / PD207R213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1706736Medicaid
LADE9683OtherRR MEDICARE
LADE9683OtherRR MEDICARE
LA5723760001Medicare NSC
LA1706736Medicaid