Provider Demographics
NPI:1386790376
Name:RED RIVER DERMATOLOGY
Entity type:Organization
Organization Name:RED RIVER DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:PRATT BERRY
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-442-9395
Mailing Address - Street 1:3335 PRESCOTT RD
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-3916
Mailing Address - Country:US
Mailing Address - Phone:318-442-9395
Mailing Address - Fax:318-442-9548
Practice Address - Street 1:3335 PRESCOTT RD
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-3916
Practice Address - Country:US
Practice Address - Phone:318-442-9395
Practice Address - Fax:318-442-9548
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA025604207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty