Basic Information
| Provider Information | |||||||||
| NPI: | 1831579077 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WK INTERNAL MEDICINE SPECIALISTS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8001 YOUREE DR STE 720 | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711152336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182123681 | ||||||||
| FaxNumber: | 3182123687 | ||||||||
| Practice Location | |||||||||
| Address1: | 8001 YOUREE DR STE 720 | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711152336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182123681 | ||||||||
| FaxNumber: | 3182123687 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2015 | ||||||||
| LastUpdateDate: | 06/17/2022 | ||||||||
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| AuthorizedOfficialLastName: | GAVIN | ||||||||
| AuthorizedOfficialFirstName: | GREG | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | NETWORK ADMINISTRATION | ||||||||
| AuthorizedOfficialTelephone: | 3182128780 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.