Provider Demographics
NPI:1659302339
Name:TEAGLE, CLARENCE RAPHIEL (MD)
Entity Type:Individual
Prefix:
First Name:CLARENCE
Middle Name:RAPHIEL
Last Name:TEAGLE
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 1:8001 YOUREE DR
Mailing Address - Street 2:SUITE 450
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71115-2302
Mailing Address - Country:US
Mailing Address - Phone:318-212-3952
Mailing Address - Fax:318-212-3955
Practice Address - Street 1:8001 YOUREE DR
Practice Address - Street 2:SUITE 450
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71115-2302
Practice Address - Country:US
Practice Address - Phone:318-212-3952
Practice Address - Fax:318-212-3955
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA009465207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1097144Medicaid
LA5H079Medicare PIN
LA5H079CW75Medicare PIN
LA1097144Medicaid