Provider Demographics
NPI:1790767481
Name:BAILEY, DONOVAN WILBUR (MD)
Entity Type:Individual
Prefix:DR
First Name:DONOVAN
Middle Name:WILBUR
Last Name:BAILEY
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 1:300 SCARBOROUGH ST
Mailing Address - Street 2:
Mailing Address - City:LAKE PROVIDENCE
Mailing Address - State:LA
Mailing Address - Zip Code:71254-3018
Mailing Address - Country:US
Mailing Address - Phone:318-559-2814
Mailing Address - Fax:318-559-4226
Practice Address - Street 1:300 SCARBOROUGH ST
Practice Address - Street 2:
Practice Address - City:LAKE PROVIDENCE
Practice Address - State:LA
Practice Address - Zip Code:71254-3018
Practice Address - Country:US
Practice Address - Phone:318-559-2814
Practice Address - Fax:318-559-4226
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA13596207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1171425Medicaid
LA13596OtherSTATE LICENSE
LA13596OtherSTATE LICENSE
LA1171425Medicaid