Provider Demographics
NPI:1356446801
Name:LOUISIANA DERMATOLOGY SKIN CANCER CENTER A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:LOUISIANA DERMATOLOGY SKIN CANCER CENTER A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:WALSWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-387-6622
Mailing Address - Street 1:201 MCMILLAN RD
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-5321
Mailing Address - Country:US
Mailing Address - Phone:318-387-6622
Mailing Address - Fax:318-387-6030
Practice Address - Street 1:201 MCMILLAN RD
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-5321
Practice Address - Country:US
Practice Address - Phone:318-387-6622
Practice Address - Fax:318-387-6030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA013630207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1396704904OtherDAVID WALSWORTH MD NPI #
LA1307360Medicaid
LA436889984AOtherBLUE CROSS
LA5D838Medicare PIN
LA1396704904OtherDAVID WALSWORTH MD NPI #
LA5J817Medicare PIN