Provider Demographics
NPI:1174567564
Name:HART, TIMOTHY MARK JR (PT)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:MARK
Last Name:HART
Suffix:JR
Gender:M
Credentials:PT
Other - Prefix:MR
Other - First Name:T
Other - Middle Name:MARK
Other - Last Name:HART
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:8660 FERN AVE STE 160
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5694
Mailing Address - Country:US
Mailing Address - Phone:318-631-7999
Mailing Address - Fax:318-631-9528
Practice Address - Street 1:2906 PLANTATION DR
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-5851
Practice Address - Country:US
Practice Address - Phone:318-746-5295
Practice Address - Fax:318-746-5297
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA03778R225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4B438C698Medicare PIN