Provider Demographics
NPI:1134548175
Name:DANZELL FAMILY MEDICAL CLINIC
Entity type:Organization
Organization Name:DANZELL FAMILY MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:DAVIS
Authorized Official - Last Name:DANZELL
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:318-631-4030
Mailing Address - Street 1:2500 KINGS HWY
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-3922
Mailing Address - Country:US
Mailing Address - Phone:318-631-4030
Mailing Address - Fax:318-631-4031
Practice Address - Street 1:2500 KINGS HWY
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-3922
Practice Address - Country:US
Practice Address - Phone:318-631-4030
Practice Address - Fax:318-631-4031
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DANZELL FAMILY MEDICAL CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-04-07
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA013603208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1307891Medicaid
LA1307891Medicaid