Provider Demographics
NPI:1932174414
Name:MCCLINTOCK, LAURA L (DO)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:L
Last Name:MCCLINTOCK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4086
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71134-0086
Mailing Address - Country:US
Mailing Address - Phone:817-731-6121
Mailing Address - Fax:817-732-8015
Practice Address - Street 1:710 SLATTERY BLVD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-4922
Practice Address - Country:US
Practice Address - Phone:817-731-6121
Practice Address - Fax:817-732-8015
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-20
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0202592084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1143227Medicaid
P00148407OtherMEDICARE RAILROAD
LA020259OtherBCBS
F25649Medicare UPIN