Basic Information
| Provider Information | |||||||||
| NPI: | 1194017418 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STEPHENSON | ||||||||
| FirstName: | LYLE | ||||||||
| MiddleName: | ROBERT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1501 KINGS HWY | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711034228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186755053 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1501 KINGS HWY | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711034228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186755053 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2011 | ||||||||
| LastUpdateDate: | 02/04/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208000000X | MD.205465 | LA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.