Provider Demographics
NPI:1861496671
Name:MICHAEL, RICHARD JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:JAMES
Last Name:MICHAEL
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 1:1500 LINE AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4648
Mailing Address - Country:US
Mailing Address - Phone:318-300-4926
Mailing Address - Fax:318-383-3951
Practice Address - Street 1:1500 LINE AVE STE 204
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4648
Practice Address - Country:US
Practice Address - Phone:318-300-4926
Practice Address - Fax:318-383-3951
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-09
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14448R208000000X
LAMD.14448R207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1125865Medicaid
LAH63307Medicare UPIN
LA4E278Medicare PIN
LA284905ZPXAMedicare PIN