Provider Demographics
NPI:1700872934
Name:HARDIN, JOHN CALVIN III (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:CALVIN
Last Name:HARDIN
Suffix:III
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 1:1801 FAIRFIELD AVE
Mailing Address - Street 2:#105
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4443
Mailing Address - Country:US
Mailing Address - Phone:318-424-2192
Mailing Address - Fax:318-484-2595
Practice Address - Street 1:1801 FAIRFIELD AVE
Practice Address - Street 2:#105
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4443
Practice Address - Country:US
Practice Address - Phone:318-424-2192
Practice Address - Fax:318-424-2595
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2012-06-08
Deactivation Date:2006-03-24
Deactivation Code:
Reactivation Date:2006-04-04
Provider Licenses
StateLicense IDTaxonomies
LA061835174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1352781Medicaid
LA721482251OtherTIN
LAB62263Medicare UPIN
LA721482251OtherTIN