Provider Demographics
NPI:1861496770
Name:CORMIER, CLINT M (MD)
Entity Type:Individual
Prefix:
First Name:CLINT
Middle Name:M
Last Name:CORMIER
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 1:2508 BERT KOUNS INDUSTRIAL LOOP STE 210
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-3175
Mailing Address - Country:US
Mailing Address - Phone:318-212-5860
Mailing Address - Fax:318-212-5865
Practice Address - Street 1:2508 BERT KOUNS INDUSTRIAL LOOP STE 210
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-3175
Practice Address - Country:US
Practice Address - Phone:318-212-5860
Practice Address - Fax:318-212-5865
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA024745207V00000X
TXM6087207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F9683OtherBCBSTX
LA1553760Medicaid
TX159052305Medicaid
TX8K0320Medicare PIN
LA1553760Medicaid