Provider Demographics
NPI:1285643908
Name:HAVENS, RICHARD TAYLOR (DPM)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:TAYLOR
Last Name:HAVENS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9308 MANSFIELD RD
Mailing Address - Street 2:STE 100
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-3160
Mailing Address - Country:US
Mailing Address - Phone:318-687-6266
Mailing Address - Fax:318-683-1023
Practice Address - Street 1:9308 MANSFIELD RD STE 100
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-3134
Practice Address - Country:US
Practice Address - Phone:318-687-6266
Practice Address - Fax:318-683-1023
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPDR073R213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1384691Medicaid
LA56030Medicare ID - Type Unspecified
LA1384691Medicaid