1386832822 NPI number — DR JONATHAN J GISCLAIR APMC DBA LAFOURCHE PODIATRY CLINIC

Table of content: (NPI 1386832822)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386832822 NPI number — DR JONATHAN J GISCLAIR APMC DBA LAFOURCHE PODIATRY CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR JONATHAN J GISCLAIR APMC DBA LAFOURCHE PODIATRY CLINIC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LAFOURCHE PODIATRY CLINIC
Provider Other Organization Name Type Code:
3
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:
1386832822
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/15/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1759
Provider Second Line Business Mailing Address:
DEPARTMENT 952
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77251-1759
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-554-5304
Provider Business Mailing Address Fax Number:
713-554-5324

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16148 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CUT OFF
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70345-3511
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-325-3668
Provider Business Practice Location Address Fax Number:
985-325-3670
Provider Enumeration Date:
10/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GISCLAIR
Authorized Official First Name:
JONATHAN
Authorized Official Middle Name:
JAMES
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
985-325-3668

Provider Taxonomy Codes

  • Taxonomy code: 213ES0131X , with the licence number:  PD0110 , 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: 1131211 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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