Provider Demographics
NPI:1902010952
Name:BIDDLE, JOHNNY RAY JR (MD)
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:RAY
Last Name:BIDDLE
Suffix:JR
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 1:630 W PRIEN LAKE RD
Mailing Address - Street 2:B 210
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-0700
Mailing Address - Country:US
Mailing Address - Phone:337-936-6893
Mailing Address - Fax:337-564-0931
Practice Address - Street 1:3608 KIRKMAN ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70607-3006
Practice Address - Country:US
Practice Address - Phone:337-936-6893
Practice Address - Fax:337-564-0931
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA05629R174400000X, 207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialist
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1347795Medicaid
LA721098713OtherTIN
LA1347795Medicaid
LA50341Medicare ID - Type Unspecified
LA50341DT25Medicare PIN