Provider Demographics
NPI:1932147725
Name:AUTRY, ERNEST DAVID (MD)
Entity Type:Individual
Prefix:
First Name:ERNEST
Middle Name:DAVID
Last Name:AUTRY
Suffix:
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 1:2900 SAINT MICHAEL DR STE 401
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-5211
Mailing Address - Country:US
Mailing Address - Phone:903-614-5372
Mailing Address - Fax:903-614-5343
Practice Address - Street 1:3311 PRESCOTT RD STE 410
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-3985
Practice Address - Country:US
Practice Address - Phone:318-442-2400
Practice Address - Fax:318-442-2427
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA05783R207V00000X
LAMD.05783R207V00000X
TXF7391208000000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009911049Medicaid
MS06323506Medicaid
LA1622664Medicaid
LA4J7137627OtherRAILROAD MEDICARE
NM63730324Medicaid
OK200290840 AMedicaid
TX205028803Medicaid
TX205028803Medicaid
LA1622664Medicaid
TXTXB106393Medicare PIN