Basic Information
| Provider Information | |||||||||
| NPI: | 1104388727 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MA | ||||||||
| FirstName: | LOUIS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 579 LAKE MANOR DR | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 387017417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6629313627 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3300 NW EXPRESSWAY | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731124418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059512277 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2019 | ||||||||
| LastUpdateDate: | 04/02/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.