1073041026 NPI number — DR. DESIRAE NICOLLE VIDAURRI PHD

Table of content: DR. DESIRAE NICOLLE VIDAURRI PHD (NPI 1073041026)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073041026 NPI number — DR. DESIRAE NICOLLE VIDAURRI PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VIDAURRI
Provider First Name:
DESIRAE
Provider Middle Name:
NICOLLE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BOLDT
Provider Other First Name:
DESRIAE
Provider Other Middle Name:
NICOLLE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1073041026
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/02/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
144 ELK PL APT 1507
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:
70112-2636
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-538-8051
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2400 CANAL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW ORLEANS
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70119-6535
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
504-507-2000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/02/2017

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: 103TC0700X , with the licence number:  0810005697 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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