Provider Demographics
NPI:1265994032
Name:BYUN-ANDERSEN, MARSHALL J (MD)
Entity type:Individual
Prefix:
First Name:MARSHALL
Middle Name:J
Last Name:BYUN-ANDERSEN
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 1:1541 KINGS HIGHWAY
Mailing Address - Street 2:FAMILY MEDICINE
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71130-3932
Mailing Address - Country:US
Mailing Address - Phone:318-626-0014
Mailing Address - Fax:
Practice Address - Street 1:1541 KINGS HIGHWAY
Practice Address - Street 2:FAMILY MEDICINE
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71130-3932
Practice Address - Country:US
Practice Address - Phone:318-626-0014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-02
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA330641207Q00000X, 207P00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2497995Medicaid