Provider Demographics
NPI:1316171358
Name:HAUGHTON, GENTRY LEE (DPM)
Entity type:Individual
Prefix:DR
First Name:GENTRY
Middle Name:LEE
Last Name:HAUGHTON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:DR
Other - First Name:GENTRY
Other - Middle Name:LEE
Other - Last Name:ROOP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPM
Mailing Address - Street 1:PO BOX 5237
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71135-5237
Mailing Address - Country:US
Mailing Address - Phone:318-798-4539
Mailing Address - Fax:318-798-4601
Practice Address - Street 1:592 UNADILLA ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-1240
Practice Address - Country:US
Practice Address - Phone:318-519-7555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-05
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXT07-2010213ES0103X
LA200048213ES0103X
TXT24-2008213ES0103X
TXT13-2009213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2158210Medicaid
LA4Q514Medicare PIN