Basic Information
| Provider Information | |||||||||
| NPI: | 1235331042 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BEAL | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | MITCHELL | ||||||||
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| OtherLastName: | MITCHELL | ||||||||
| OtherFirstName: | EMILY | ||||||||
| OtherMiddleName: | LAUREN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1501 KINGS HWY | ||||||||
| Address2: | DEPARTMENT OF MED&PEDS | ||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711034228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3188132528 | ||||||||
| FaxNumber: | 3188132565 | ||||||||
| Practice Location | |||||||||
| Address1: | 1501 KINGS HWY | ||||||||
| Address2: | DEPARTMENT OF MED&PEDS | ||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 71103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3188132528 | ||||||||
| FaxNumber: | 3188132565 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2007 | ||||||||
| LastUpdateDate: | 08/20/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 200123 | LA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 200123 | LA | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1059668 | 05 | LA | MEDICAID |