Provider Demographics
NPI:1609918945
Name:TROUP, RUDOLPH W JR (OD)
Entity Type:Individual
Prefix:DR
First Name:RUDOLPH
Middle Name:W
Last Name:TROUP
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8889 JEWELLA AVE.
Mailing Address - Street 2:STE. E
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-2138
Mailing Address - Country:US
Mailing Address - Phone:318-686-5227
Mailing Address - Fax:318-686-5283
Practice Address - Street 1:8889 JEWELLA AVE
Practice Address - Street 2:SUITE D
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-2138
Practice Address - Country:US
Practice Address - Phone:318-686-5227
Practice Address - Fax:318-686-5242
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2009-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA725-178T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1123838Medicaid
LA72-1431713OtherTAX ID #
LA725-178TOtherLICENSE #
P00090047OtherPALMETTO GBA- RR MEDICARE
P00090047OtherPALMETTO GBA- RR MEDICARE
LA49157Medicare ID - Type Unspecified
T19621Medicare UPIN
LA72-1431713OtherTAX ID #
1296220001Medicare NSC
LAT19621Medicare UPIN
49157Medicare PIN