Individual
MINDIE MICHELLE KAVANAUGH
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
1501 KINGS HWY, DEPARTMENT OF INTERNAL MEDICINE, SHREVEPORT, LA 71103-4228
(318) 813-1431
(318) 813-1444
Mailing address
1501 KINGS HWY, DEPARTMENT OF INTERNAL MEDICINE, SHREVEPORT, LA 71103-4228
(318) 675-5915
(318) 675-5948
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
203912
LA
207RH0003X
Hematology & Oncology Physician
Primary
203912
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
19933147
—
LA
01
—
39108YH54
MEDICARE - PTAN
LA
Enumeration date
04/14/2009
Last updated
04/29/2016
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