NPIMap

Organization Active NPI

Divine Health Primary Care Clinic, LLC

Doing business as Divine Health and Primary Care Clinic

  • Internal Medicine Physician
  • Ruston, LA
National Provider Identifier
1548528854
Registry record updated Apr 25, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
License
203609 Issued in LA
Legal business name
DIVINE HEALTH PRIMARY CARE CLINIC, LLC
Doing business as
Divine Health and Primary Care Clinic
Practice address
1401 Ezell Street
Ruston, LA 71270-7218
Phone
(318) 259-1204
Fax
(318) 259-1255
NPI assigned
Apr 25, 2012
Last updated
Apr 25, 2012By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 25, 2012

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Ofundem Rose Gwan, M.D.NPI 1245440940
Title
Owner/Physician
Phone
(318) 259-1204

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Internal Medicine Physician 207R00000X 203609 LA Primary

Addresses

Primary practice location

1401 Ezell Street
Ruston, LA 71270-7218

Mailing address

1401 Ezell Street
Ruston, LA 71270-7218
Phone (318) 259-1204

Other identifiers 1

IdentifierTypeStateIssuer
1245440940OtherLAINDIVIDUAL NPI

Other names 1

  • Divine Health and Primary Care Clinic Doing business as

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1335312000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1335312000000",
    "number": "1548528854",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1401 EZELL STREET",
            "city": "RUSTON",
            "state": "LA",
            "postal_code": "712707218",
            "telephone_number": "318-259-1204",
            "fax_number": "318-259-1255"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1401 EZELL STREET",
            "city": "RUSTON",
            "state": "LA",
            "postal_code": "712707218",
            "telephone_number": "318-259-1204",
            "fax_number": "318-259-1255"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DIVINE HEALTH PRIMARY CARE CLINIC, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-04-25",
        "last_updated": "2012-04-25",
        "status": "A",
        "authorized_official_last_name": "GWAN",
        "authorized_official_first_name": "OFUNDEM",
        "authorized_official_middle_name": "ROSE",
        "authorized_official_title_or_position": "OWNER/PHYSICIAN",
        "authorized_official_telephone_number": "318-259-1204",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "LA",
            "license": "203609",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "INDIVIDUAL NPI",
            "identifier": "1245440940",
            "state": "LA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Divine Health and Primary Care Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Ruston, LA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 25, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.