Provider Demographics
NPI:1962822965
Name:HUDDLESTON, LISE M (MD)
Entity Type:Individual
Prefix:
First Name:LISE
Middle Name:M
Last Name:HUDDLESTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LISE
Other - Middle Name:
Other - Last Name:MURRELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8001 YOUREE DR STE 600
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71115-2345
Mailing Address - Country:US
Mailing Address - Phone:318-212-3890
Mailing Address - Fax:318-212-3888
Practice Address - Street 1:8001 YOUREE DR STE 600
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71115-2345
Practice Address - Country:US
Practice Address - Phone:318-212-3890
Practice Address - Fax:318-212-3888
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-17
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LA308274207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty