Provider Demographics
NPI:1609967017
Name:MYCHASKIW, GEORGE II (DO)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:MYCHASKIW
Suffix:II
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1512 W KIRBY PL
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-3822
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1541 KINGS HWY
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-626-0000
Practice Address - Fax:318-629-4833
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA321616207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00112233Medicaid
MSP00622803OtherRAILROAD MEDICARE
MS050069240OtherRAILROAD MEDICARE
MS00112233Medicaid
MS512I050018Medicare PIN
MS050000464Medicare PIN