Basic Information
| Provider Information | |||||||||
| NPI: | 1821228909 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANNE | ||||||||
| FirstName: | PRATIBHA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1625 DAVID RAINES RD | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711075899 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3184252252 | ||||||||
| FaxNumber: | 3182273357 | ||||||||
| Practice Location | |||||||||
| Address1: | 1625 DAVID RAINES RD | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711075899 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3184252252 | ||||||||
| FaxNumber: | 3182273357 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2009 | ||||||||
| LastUpdateDate: | 10/14/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 203834 | LA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 06568919 | 01 | ECFMG | OTHER | 203834 | 01 | LA | STATE LICENSE | OTHER |