Provider Demographics
NPI:1932490554
Name:KITCHELL, MICHAEL THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:THOMAS
Last Name:KITCHELL
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 1:1666 E BERT KOUN LOOP STE 105
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5718
Mailing Address - Country:US
Mailing Address - Phone:318-212-3520
Mailing Address - Fax:318-212-3525
Practice Address - Street 1:1666 E BERT KOUN LOOP STE 105
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5718
Practice Address - Country:US
Practice Address - Phone:318-212-3520
Practice Address - Fax:318-212-3525
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.206535207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2144219Medicaid
12653186OtherCAQH
LA715GMOtherMEDICARE