Provider Demographics
NPI:1518975895
Name:EUGENE, EDWIDG (MD,)
Entity Type:Individual
Prefix:DR
First Name:EDWIDG
Middle Name:
Last Name:EUGENE
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 1:5619 MIRADOR CIR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71119-4009
Mailing Address - Country:US
Mailing Address - Phone:318-539-1041
Mailing Address - Fax:318-635-7224
Practice Address - Street 1:2001 DOCTORS DR
Practice Address - Street 2:
Practice Address - City:SPRINGHILL
Practice Address - State:LA
Practice Address - Zip Code:71075-4526
Practice Address - Country:US
Practice Address - Phone:318-539-1041
Practice Address - Fax:318-539-4097
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA05402R207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1316211Medicaid
LA1316211Medicaid
LAB62999Medicare UPIN