Provider Demographics
NPI:1942410980
Name:CREEKMORE, TINA L (MD)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:L
Last Name:CREEKMORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7301 HENNESSY BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-4384
Mailing Address - Country:US
Mailing Address - Phone:225-765-6453
Mailing Address - Fax:225-768-2424
Practice Address - Street 1:7301 HENNESSY BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4384
Practice Address - Country:US
Practice Address - Phone:225-765-6453
Practice Address - Fax:225-768-2424
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA026892207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA07057Medicaid
LA1072052Medicaid
LA1072052Medicaid
LA07057Medicaid