Provider Demographics
NPI:1316228984
Name:CHOICE PEDIATRICS, LLC
Entity Type:Organization
Organization Name:CHOICE PEDIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:OLABODE
Authorized Official - Middle Name:O
Authorized Official - Last Name:DESALU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-290-3673
Mailing Address - Street 1:PO BOX 5866
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71135-5866
Mailing Address - Country:US
Mailing Address - Phone:318-290-3673
Mailing Address - Fax:318-290-3672
Practice Address - Street 1:6930 FERN AVE
Practice Address - Street 2:SUITE 150
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-4100
Practice Address - Country:US
Practice Address - Phone:318-290-3673
Practice Address - Fax:318-290-3672
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-08
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15345R208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty