Provider Demographics
NPI:1285674820
Name:VEKOVIUS, BRYAN JOHANNES (MD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:JOHANNES
Last Name:VEKOVIUS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 ASHLEY RIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-7228
Mailing Address - Country:US
Mailing Address - Phone:318-675-3733
Mailing Address - Fax:
Practice Address - Street 1:450 ASHLEY RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-7228
Practice Address - Country:US
Practice Address - Phone:318-375-3733
Practice Address - Fax:318-675-3734
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAL023263207WX0109X, 207WX0200X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207WX0109XAllopathic & Osteopathic PhysiciansOphthalmologyNeuro-ophthalmology
No207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX154644202OtherTEXAS MEDICAID
LA170085727OtherGROUP NPI #
TX0238TUOtherBLUE CROSS BLUE SHIELD
LA1495867Medicaid
LA180044593OtherRAILROAD MEDICARE
LAG50885Medicare UPIN
LA5CB43Medicare ID - Type UnspecifiedLOUISIANA MEDICARE