Provider Demographics
NPI:1972966349
Name:WILLARD-NIENDORFF, ROBIN (MD)
Entity Type:Individual
Prefix:
First Name:ROBIN
Middle Name:
Last Name:WILLARD-NIENDORFF
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 1:1501 KINGS HWY
Mailing Address - Street 2:SURGERY
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4228
Mailing Address - Country:US
Mailing Address - Phone:318-813-2655
Mailing Address - Fax:318-813-2673
Practice Address - Street 1:1501 KINGS HWY
Practice Address - Street 2:SURGERY
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-813-2655
Practice Address - Fax:318-813-2673
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-01
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program