Provider Demographics
NPI:1669472155
Name:HEARNE, SANDERS FOWLER (MD)
Entity Type:Individual
Prefix:DR
First Name:SANDERS
Middle Name:FOWLER
Last Name:HEARNE
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 1:1811 E BERT KOUNS
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71115
Mailing Address - Country:US
Mailing Address - Phone:318-222-3695
Mailing Address - Fax:318-424-0717
Practice Address - Street 1:1811 E BERT KOUNS
Practice Address - Street 2:SUITE 100
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71115
Practice Address - Country:US
Practice Address - Phone:318-222-3695
Practice Address - Fax:318-424-0717
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2009-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA013230207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1362867Medicaid
LA1362867Medicaid
LAB89499Medicare UPIN