Basic Information
| Provider Information | |||||||||
| NPI: | 1225084536 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NETTERVILLE | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | KEVIN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10326 GOLDSBERRY | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 71106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3187980998 | ||||||||
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| Practice Location | |||||||||
| Address1: | ONE ST MARY PLACE | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 71101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186814500 | ||||||||
| FaxNumber: | 3186814177 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 207P00000X | 12640R | LA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1541800 | 05 | LA | MEDICAID |