Provider Demographics
NPI:1437114824
Name:SISKRON, FREDRIC T IV (MD)
Entity Type:Individual
Prefix:
First Name:FREDRIC
Middle Name:T
Last Name:SISKRON
Suffix:IV
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 1:2551 GREENWOOD RD
Mailing Address - Street 2:SUITE 140
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-3981
Mailing Address - Country:US
Mailing Address - Phone:318-212-8899
Mailing Address - Fax:318-212-8806
Practice Address - Street 1:2551 GREENWOOD RD
Practice Address - Street 2:SUITE 140
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-3981
Practice Address - Country:US
Practice Address - Phone:318-212-8899
Practice Address - Fax:318-212-8806
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA023873208800000X
IN01071979A208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1054232Medicaid
LA1054232Medicaid