1922290949 NPI number — DR. JENNIFER M MONCADA O.D.

Table of content: DR. JENNIFER M MONCADA O.D. (NPI 1922290949)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922290949 NPI number — DR. JENNIFER M MONCADA O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MONCADA
Provider First Name:
JENNIFER
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1922290949
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/09/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1518 W AIRLINE HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LA PLACE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70068-3725
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
985-652-4097
Provider Business Mailing Address Fax Number:
985-652-9917

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1518 W AIRLINE HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA PLACE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70068-3725
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-652-4097
Provider Business Practice Location Address Fax Number:
985-652-9917
Provider Enumeration Date:
08/14/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OPC 4360 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 4634 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 1572-604T , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0000025360 . This is a "RI BCBS" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: AA96447 . This is a "HARVARD PILGRIM" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1887897 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0715484 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".