Provider Demographics
NPI:1952339038
Name:EVERTON, VICTORIA L (MD)
Entity Type:Individual
Prefix:DR
First Name:VICTORIA
Middle Name:L
Last Name:EVERTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 LOUISIANA AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-3910
Mailing Address - Country:US
Mailing Address - Phone:318-212-8574
Mailing Address - Fax:318-212-4153
Practice Address - Street 1:2530 BERT KOUNS LOOP
Practice Address - Street 2:SUITE 138
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-3132
Practice Address - Country:US
Practice Address - Phone:318-212-5911
Practice Address - Fax:318-212-5168
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11085R207Q00000X
LAMD11085R207PE0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1584258Medicaid
NYIA0627Medicare ID - Type Unspecified
NYI21834Medicare UPIN
LA4K117F600Medicare ID - Type Unspecified