Provider Demographics
NPI:1942414552
Name:OVERDYKE, JEFFREY T (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:T
Last Name:OVERDYKE
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 1:1202 LOUISIANA AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-3910
Mailing Address - Country:US
Mailing Address - Phone:318-212-8574
Mailing Address - Fax:318-212-4153
Practice Address - Street 1:2508 BERT KOUNS LOOP
Practice Address - Street 2:SUITE 303
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-3133
Practice Address - Country:US
Practice Address - Phone:318-212-5850
Practice Address - Fax:318-212-5855
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2031792084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4M560DL73OtherMEDICARE PTAN
LA1810975Medicaid