Provider Demographics
NPI:1467526178
Name:DENNIE, RAYMOND EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:EDWARD
Last Name:DENNIE
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 1:6121 FERN AVE
Mailing Address - Street 2:79 PIERREMONT PLACE
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-4155
Mailing Address - Country:US
Mailing Address - Phone:318-797-1356
Mailing Address - Fax:318-212-4545
Practice Address - Street 1:2724 GREENWOOD RD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71109-4635
Practice Address - Country:US
Practice Address - Phone:318-212-4248
Practice Address - Fax:318-212-4545
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4185R174400000X
LAAD8213326 DEA332900000X
LAMD04185R332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No332900000XSuppliersNon-Pharmacy Dispensing Site
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1182621Medicaid
LA513761Medicare ID - Type Unspecified
LA1182621Medicaid