Provider Demographics
NPI:1417980533
Name:MADDEN, MICHAEL LORING (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LORING
Last Name:MADDEN
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 1:1501 KINGS HWY
Mailing Address - Street 2:DEPARTMENT OF FAMILY MEDICINE
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4228
Mailing Address - Country:US
Mailing Address - Phone:318-441-1061
Mailing Address - Fax:318-484-2225
Practice Address - Street 1:1501 KINGS HWY
Practice Address - Street 2:DEPARTMENT OF FAMILY MEDICINE
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-441-1061
Practice Address - Fax:318-484-2225
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA010746207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1102440Medicaid
LA53576F600Medicare ID - Type Unspecified
LAB64711Medicare UPIN