Provider Demographics
NPI:1427088079
Name:MAINOUS, MARK RICHARD (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:RICHARD
Last Name:MAINOUS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8001 YOUREE DR
Mailing Address - Street 2:SUITE 840
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71115-2302
Mailing Address - Country:US
Mailing Address - Phone:318-212-2846
Mailing Address - Fax:318-212-2845
Practice Address - Street 1:8001 YOUREE DR
Practice Address - Street 2:SUITE 840
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71115-2302
Practice Address - Country:US
Practice Address - Phone:318-212-2846
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA07555R2086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1968579Medicaid
LA5R761CV60Medicare PIN
LA5R761Medicare PIN
LA5R761DE54Medicare PIN
F59095Medicare UPIN
LA1968579Medicaid
LA5CV90Medicare PIN