Provider Demographics
NPI:1457329120
Name:VIGEN, MARK P (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:P
Last Name:VIGEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3341 YOUREE DR STE 20A
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-2149
Mailing Address - Country:US
Mailing Address - Phone:318-425-2000
Mailing Address - Fax:318-424-2601
Practice Address - Street 1:3341 YOUREE DR STE 20A
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-2149
Practice Address - Country:US
Practice Address - Phone:318-425-2000
Practice Address - Fax:318-424-2601
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA280103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA20559OtherBLUE CROSS/BLUE SHIELD
LA009755OtherVALUE OPTIONS