1811980675 NPI number — DR. JENNESS DONIPHAN COURTNEY III MD

Table of content: DR. JENNESS DONIPHAN COURTNEY III MD (NPI 1811980675)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811980675 NPI number — DR. JENNESS DONIPHAN COURTNEY III MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COURTNEY
Provider First Name:
JENNESS
Provider Middle Name:
DONIPHAN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
III
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1811980675
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/28/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1801 FAIRFIELD AVE
Provider Second Line Business Mailing Address:
SUITE 411
Provider Business Mailing Address City Name:
SHREVEPORT
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71101-4443
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-424-4224
Provider Business Mailing Address Fax Number:
318-424-4044

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1801 FAIRFIELD AVE
Provider Second Line Business Practice Location Address:
SUITE 411
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71101-4443
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-424-4224
Provider Business Practice Location Address Fax Number:
318-424-4044
Provider Enumeration Date:
08/26/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208100000X , with the licence number:  023053 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208100000X , with the licence number: E1524 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 078793901 . This is a "TX MCD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1494135 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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