Provider Demographics
NPI:1780848580
Name:WK ARK-LA-TEX NEONATOLOGY
Entity Type:Organization
Organization Name:WK ARK-LA-TEX NEONATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NETWORK/ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GREG
Authorized Official - Middle Name:J
Authorized Official - Last Name:GAVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-212-4571
Mailing Address - Street 1:1202 LOUISIANA AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-3910
Mailing Address - Country:US
Mailing Address - Phone:318-212-8946
Mailing Address - Fax:
Practice Address - Street 1:2510 BERT KOUNS LOOP
Practice Address - Street 2:ROOM 215
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-3119
Practice Address - Country:US
Practice Address - Phone:318-212-5970
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-11
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1816671Medicaid