Provider Demographics
NPI:1356713440
Name:DELTA NEPHROLOGY LLC
Entity type:Organization
Organization Name:DELTA NEPHROLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:G
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-226-0809
Mailing Address - Street 1:PO BOX 1684
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71165-1684
Mailing Address - Country:US
Mailing Address - Phone:318-424-4008
Mailing Address - Fax:
Practice Address - Street 1:745 OLIVE ST
Practice Address - Street 2:SUITE 200
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-2246
Practice Address - Country:US
Practice Address - Phone:318-226-0809
Practice Address - Fax:318-226-0812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-28
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty