Provider Demographics
NPI:1881009595
Name:GENTRY HAUGHTON, LLC
Entity Type:Organization
Organization Name:GENTRY HAUGHTON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DPM
Authorized Official - Prefix:
Authorized Official - First Name:GENTRY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:HAUGHTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-519-7555
Mailing Address - Street 1:PO BOX 5237
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71135-5237
Mailing Address - Country:US
Mailing Address - Phone:318-798-4539
Mailing Address - Fax:318-798-4601
Practice Address - Street 1:1505 E BERT KOUN LOOP
Practice Address - Street 2:SUITE 101
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5723
Practice Address - Country:US
Practice Address - Phone:318-519-7555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-23
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LADPM.200048213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty