Basic Information
| Provider Information | |||||||||
| NPI: | 1356713440 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DELTA NEPHROLOGY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1684 | ||||||||
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| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711651684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3184244008 | ||||||||
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| Practice Location | |||||||||
| Address1: | 745 OLIVE ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711042246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182260809 | ||||||||
| FaxNumber: | 3182260812 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2015 | ||||||||
| LastUpdateDate: | 10/28/2015 | ||||||||
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| AuthorizedOfficialLastName: | WHITE | ||||||||
| AuthorizedOfficialFirstName: | RANDALL | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3182260809 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
No ID Information.