Provider Demographics
NPI:1720013261
Name:ADCOCK, DEBORAH K (MD)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:K
Last Name:ADCOCK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2533 BERT KOUNS INDUSTRIAL LOOP
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118
Mailing Address - Country:US
Mailing Address - Phone:318-698-8889
Mailing Address - Fax:318-698-8893
Practice Address - Street 1:2533 BERT KOUNS INDUSTRIAL LOOP
Practice Address - Street 2:SUITE 104
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118
Practice Address - Country:US
Practice Address - Phone:318-698-8889
Practice Address - Fax:318-698-8893
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA08006R174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAC12615Medicare UPIN
LA261396YLSJMedicare PIN