Provider Demographics
NPI:1912901794
Name:KNIGHT, CHARLES D JR (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:D
Last Name:KNIGHT
Suffix:JR
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 1:1455 E BERT KOUNS INDUSTRIAL LOOP
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-6000
Mailing Address - Country:US
Mailing Address - Phone:318-798-4691
Mailing Address - Fax:318-798-4412
Practice Address - Street 1:1455 E BERT KOUNS INDUSTRIAL LOOP STE 202
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5634
Practice Address - Country:US
Practice Address - Phone:318-798-4691
Practice Address - Fax:318-798-4412
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA06896R2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1053315846OtherGROUP NPI NUMBER
TX153013101OtherTEXAS MEDICAID NUMBER
LA020021594OtherRAILROAD MEDICARE NUMBER
LA1376426Medicaid
LAD79800Medicare UPIN
LA1376426Medicaid
LA52224Medicare ID - Type Unspecified