Provider Demographics
NPI:1508813742
Name:ENSMINGER, BOBBY TAYLOR (MD)
Entity Type:Individual
Prefix:DR
First Name:BOBBY
Middle Name:TAYLOR
Last Name:ENSMINGER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:BOBBY
Other - Middle Name:TAYLOR
Other - Last Name:ENSMINGER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:411 E VAUGHN AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-5977
Mailing Address - Country:US
Mailing Address - Phone:318-255-8271
Mailing Address - Fax:318-255-8260
Practice Address - Street 1:1200 CELEBRITY DR STE 1
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-3894
Practice Address - Country:US
Practice Address - Phone:318-232-1590
Practice Address - Fax:318-232-1221
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-30
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAL15027R207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1163384Medicaid
LA4F364Medicare PIN
LAH54006Medicare UPIN