Provider Demographics
NPI:1477732188
Name:RONALD A GOEBEL & MARK P VIGEN PTR
Entity Type:Organization
Organization Name:RONALD A GOEBEL & MARK P VIGEN PTR
Other - Org Name:GOEBEL & VIGEN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:A
Authorized Official - Last Name:GOEBEL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:318-425-2000
Mailing Address - Street 1:3341 YOUREE DR STE 20A
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-2149
Mailing Address - Country:US
Mailing Address - Phone:318-425-2000
Mailing Address - Fax:318-424-2601
Practice Address - Street 1:3341 YOUREE DR STE 20A
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-2149
Practice Address - Country:US
Practice Address - Phone:318-425-2000
Practice Address - Fax:318-424-2601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-30
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA57759Medicare PIN