Provider Demographics
NPI:1487652707
Name:ALLEN, MICHAEL DALE (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DALE
Last Name:ALLEN
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 1:3704 NORTH BLVD, STE 1
Mailing Address - Street 2:PO BOX 6284
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71307-6284
Mailing Address - Country:US
Mailing Address - Phone:318-442-8399
Mailing Address - Fax:318-448-9897
Practice Address - Street 1:3704 NORTH BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-3606
Practice Address - Country:US
Practice Address - Phone:318-442-8399
Practice Address - Fax:318-448-9897
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11265R174400000X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1664243Medicaid
LA300082907OtherRAILROAD MEDICARE
LA5W341Medicare PIN
LA1664243Medicaid