Provider Demographics
NPI:1740258102
Name:HINES, CARL HENRY (MD)
Entity type:Individual
Prefix:DR
First Name:CARL
Middle Name:HENRY
Last Name:HINES
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 1:1114 HOMER RD
Mailing Address - Street 2:
Mailing Address - City:MINDEN
Mailing Address - State:LA
Mailing Address - Zip Code:71055-3028
Mailing Address - Country:US
Mailing Address - Phone:318-371-1395
Mailing Address - Fax:318-377-5932
Practice Address - Street 1:1114 HOMER RD
Practice Address - Street 2:
Practice Address - City:MINDEN
Practice Address - State:LA
Practice Address - Zip Code:71055-3028
Practice Address - Country:US
Practice Address - Phone:318-371-1395
Practice Address - Fax:318-377-5932
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-10
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA015051207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1199141Medicaid
LA5L662Medicare ID - Type UnspecifiedMEDICARE
LA1199141Medicaid