Provider Demographics
NPI:1821228909
Name:ANNE, PRATIBHA (MD)
Entity Type:Individual
Prefix:
First Name:PRATIBHA
Middle Name:
Last Name:ANNE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1625 DAVID RAINES RD
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-5899
Mailing Address - Country:US
Mailing Address - Phone:318-425-2252
Mailing Address - Fax:318-227-3357
Practice Address - Street 1:1625 DAVID RAINES RD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107-5899
Practice Address - Country:US
Practice Address - Phone:318-425-2252
Practice Address - Fax:318-227-3357
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-22
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA203834207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
06568919OtherECFMG
LA203834OtherSTATE LICENSE