Provider Demographics
NPI:1962448977
Name:VICKI S COBB MD & WILLIS-KNIGHTON MEDICAL CENTER
Entity Type:Organization
Organization Name:VICKI S COBB MD & WILLIS-KNIGHTON MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NETWORK ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:J
Authorized Official - Last Name:GAVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-965-9644
Mailing Address - Street 1:4707 PALMETTO RD
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:LA
Mailing Address - Zip Code:71006-9712
Mailing Address - Country:US
Mailing Address - Phone:318-965-9644
Mailing Address - Fax:318-965-9640
Practice Address - Street 1:4707 PALMETTO RD
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:LA
Practice Address - Zip Code:71006-9712
Practice Address - Country:US
Practice Address - Phone:318-965-9644
Practice Address - Fax:318-965-9640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5CS34Medicare ID - Type Unspecified