Basic Information
| Provider Information | |||||||||
| NPI: | 1942741376 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PERMENTER | ||||||||
| FirstName: | CARA | ||||||||
| MiddleName: | MICCOLI | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2900 SAINT MICHAEL DR STE 401 | ||||||||
| Address2: | |||||||||
| City: | TEXARKANA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 755035211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036145372 | ||||||||
| FaxNumber: | 9036145343 | ||||||||
| Practice Location | |||||||||
| Address1: | 9220 ELLERBE RD STE 700 | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711066709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186815282 | ||||||||
| FaxNumber: | 3186815284 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2017 | ||||||||
| LastUpdateDate: | 07/29/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 312349 | LA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2442457 | 05 | LA | MEDICAID |