Provider Demographics
NPI:1609049220
Name:SHOLL, ANDREW BLAKE (MD)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:BLAKE
Last Name:SHOLL
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:PO BOX 3780
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38803-3780
Mailing Address - Country:US
Mailing Address - Phone:318-841-9526
Mailing Address - Fax:
Practice Address - Street 1:2915 MISSOURI AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71109-4327
Practice Address - Country:US
Practice Address - Phone:318-621-8820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-03
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0050723207ZP0102X
LAMD.206511207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2346202Medicaid