1063411361 NPI number — DR. MAHMOUD DAFTARY MD

Table of content: DR. MAHMOUD DAFTARY MD (NPI 1063411361)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063411361 NPI number — DR. MAHMOUD DAFTARY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAFTARY
Provider First Name:
MAHMOUD
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1063411361
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/19/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1514 JEFFERSON HIGHWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW ORLEANS
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70121
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
504-842-4000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2750 GAUSE BLVD. EAST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SLIDELL
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70461
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-639-3777
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/19/2005

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: 174400000X , with the licence number:  04535R , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208800000X , with the licence number: MD.04535R , 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: 00122909 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1329444 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00396221 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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