Provider Demographics
NPI:1861495822
Name:BRANNAN, MICHAEL BIVENS (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:BIVENS
Last Name:BRANNAN
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:PO BOX 38150
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71133-8150
Mailing Address - Country:US
Mailing Address - Phone:318-631-9121
Mailing Address - Fax:318-631-9688
Practice Address - Street 1:3217 MABEL ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4022
Practice Address - Country:US
Practice Address - Phone:318-631-9121
Practice Address - Fax:318-631-9688
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA04481R207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1195839Medicaid
LA50436Medicare ID - Type Unspecified
LA1195839Medicaid