Provider Demographics
NPI:1740357722
Name:BICKNELL, JOHN ERIC SR (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ERIC
Last Name:BICKNELL
Suffix:SR
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 1:7925 YOUREE DRIVE
Mailing Address - Street 2:SUITE 280A
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105
Mailing Address - Country:US
Mailing Address - Phone:318-798-6833
Mailing Address - Fax:318-798-6835
Practice Address - Street 1:7925 YOUREE DRIVE
Practice Address - Street 2:SUITE 280A
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105
Practice Address - Country:US
Practice Address - Phone:318-798-6833
Practice Address - Fax:318-798-6835
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA016810208100000X, 204R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No204R00000XAllopathic & Osteopathic PhysiciansElectrodiagnostic Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1392715Medicaid
TXX9X029868Medicaid
E06783Medicare UPIN
TXX9X029868Medicaid