Provider Demographics
NPI:1528587441
Name:SHREVEPORT EYE SPECIALISTS, LLC
Entity Type:Organization
Organization Name:SHREVEPORT EYE SPECIALISTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:H
Authorized Official - Last Name:VAN NORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-703-5655
Mailing Address - Street 1:1801 FAIRFIELD AVE STE 207
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4460
Mailing Address - Country:US
Mailing Address - Phone:318-703-5655
Mailing Address - Fax:318-606-5470
Practice Address - Street 1:1801 FAIRFIELD AVE STE 207
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4460
Practice Address - Country:US
Practice Address - Phone:318-489-5949
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-12
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.024870207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty