Provider Demographics
NPI:1306041454
Name:TATE, JAMESETTA WARD (MD)
Entity Type:Individual
Prefix:MRS
First Name:JAMESETTA
Middle Name:WARD
Last Name:TATE
Suffix:
Gender:F
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:PO BOX 29591
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71149-9591
Mailing Address - Country:US
Mailing Address - Phone:318-603-0440
Mailing Address - Fax:
Practice Address - Street 1:6823 PINES RD
Practice Address - Street 2:A
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71129-5205
Practice Address - Country:US
Practice Address - Phone:318-603-0440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.015091207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1072362Medicaid
LA4K942DB77Medicare Oscar/Certification