Provider Demographics
NPI:1962629212
Name:DR ALLEN J HERBERT A MEDICAL CORP
Entity Type:Organization
Organization Name:DR ALLEN J HERBERT A MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALLEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:HERBERT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-255-7474
Mailing Address - Street 1:PO BOX 1768
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71166-1768
Mailing Address - Country:US
Mailing Address - Phone:318-677-7450
Mailing Address - Fax:318-425-5815
Practice Address - Street 1:411 E VAUGHN AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-5972
Practice Address - Country:US
Practice Address - Phone:318-255-7474
Practice Address - Fax:318-254-5278
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD010285207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1126403Medicaid
LA5DD33Medicare PIN