Provider Demographics
NPI:1992844435
Name:TALIAFERRO, HENRY GOVAN (MD)
Entity Type:Individual
Prefix:DR
First Name:HENRY
Middle Name:GOVAN
Last Name:TALIAFERRO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:130 DESIARD ST
Mailing Address - Street 2:SUITE 355
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-7319
Mailing Address - Country:US
Mailing Address - Phone:318-807-7875
Mailing Address - Fax:318-812-6603
Practice Address - Street 1:2516 BROADMOOR BLVD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-2988
Practice Address - Country:US
Practice Address - Phone:318-812-1125
Practice Address - Fax:318-812-1129
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA012237207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1194972Medicaid
LAD04270Medicare UPIN
LA1194972Medicaid
LA55309F600Medicare PIN