Provider Demographics
NPI:1700085727
Name:BRYAN VEKOVIUS M.D. LLC
Entity Type:Organization
Organization Name:BRYAN VEKOVIUS M.D. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:JOHANNES
Authorized Official - Last Name:VEKOVIUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-675-3733
Mailing Address - Street 1:450 ASHLEY RIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-7228
Mailing Address - Country:US
Mailing Address - Phone:318-675-3733
Mailing Address - Fax:318-675-3734
Practice Address - Street 1:450 ASHLEY RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106
Practice Address - Country:US
Practice Address - Phone:318-675-3733
Practice Address - Fax:318-675-3734
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-11
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALO 23263207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1285674820OtherINDIVIDAL NPI#
LA1285674820OtherINDIVIDAL NPI#
LAG50885Medicare UPIN