Provider Demographics
NPI:1356403687
Name:RICHIE, JOHN N (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:N
Last Name:RICHIE
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 1:2508 BERT KOUNS INDUSTRIAL LOOP
Mailing Address - Street 2:SUITE 203
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-3133
Mailing Address - Country:US
Mailing Address - Phone:318-688-9955
Mailing Address - Fax:318-688-9929
Practice Address - Street 1:2508 BERT KOUNS INDUSTRIAL LOOP
Practice Address - Street 2:SUITE 203
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-3133
Practice Address - Country:US
Practice Address - Phone:318-688-9955
Practice Address - Fax:318-688-9929
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.010298174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1169439Medicaid
LA720819375711180000OtherTRICARE
LAB89788Medicare UPIN
LA1169439Medicaid