Basic Information
Provider Information
NPI: 1003291006
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: PILLAY
FirstName: VICKREN
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1501 KINGS HWY
Address2:  
City: SHREVEPORT
State: LA
PostalCode: 711034228
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 1501 KINGS HWY
Address2:  
City: SHREVEPORT
State: LA
PostalCode: 711034228
CountryCode: US
TelephoneNumber: 3186755053
FaxNumber:  
Other Information
ProviderEnumerationDate: 07/21/2015
LastUpdateDate: 07/21/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
390200000X  Y Student, Health CareStudent in an Organized Health Care Education/Training Program 

No ID Information.


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