Provider Demographics
NPI:1942741376
Name:PERMENTER, CARA MICCOLI (MD)
Entity Type:Individual
Prefix:
First Name:CARA
Middle Name:MICCOLI
Last Name:PERMENTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2900 SAINT MICHAEL DR STE 401
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-5211
Mailing Address - Country:US
Mailing Address - Phone:903-614-5372
Mailing Address - Fax:903-614-5343
Practice Address - Street 1:9220 ELLERBE RD STE 700
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-6709
Practice Address - Country:US
Practice Address - Phone:318-681-5282
Practice Address - Fax:318-681-5284
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-18
Last Update Date:2020-07-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
LA312349207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2442457Medicaid