Provider Demographics
NPI:1619937802
Name:UNDERWOOD, JOHN G II (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:G
Last Name:UNDERWOOD
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:919 HIDDEN RDG
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-3813
Mailing Address - Country:US
Mailing Address - Phone:469-282-2711
Mailing Address - Fax:469-282-0996
Practice Address - Street 1:9091 ELLERBE RD
Practice Address - Street 2:STE 200
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-6738
Practice Address - Country:US
Practice Address - Phone:318-681-1630
Practice Address - Fax:318-681-1632
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2023-03-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
LAL03841207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1300675Medicaid
LA7930OtherSTATE DEA
AU7338216OtherCONTROLLED DEA
LA7930OtherSTATE DEA
LA5L633BC11Medicare PIN