Provider Demographics
NPI:1982608659
Name:WASHBURNE, WILLARD F (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLARD
Middle Name:F
Last Name:WASHBURNE
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 1:1455 E BERT KOUNS LOOP
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5634
Mailing Address - Country:US
Mailing Address - Phone:318-798-4544
Mailing Address - Fax:318-798-4557
Practice Address - Street 1:1455 E BERT KOUNS LOOP
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:318-798-4544
Practice Address - Fax:318-798-4557
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2009-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA012342207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1053315846OtherGROUP NPI NUMBER
LAP00049384OtherRAILROAD MEDICARE
TX051692402OtherTEXAS MEDICAID NUMBER
LA1141933Medicaid
LA5K672Medicare ID - Type Unspecified
LA5K6726742Medicare PIN
LA1141933Medicaid