1528315280 NPI number — GENE THOMAS CALLAIS JR. MD

Table of content: GENE THOMAS CALLAIS JR. MD (NPI 1528315280)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528315280 NPI number — GENE THOMAS CALLAIS JR. MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CALLAIS
Provider First Name:
GENE
Provider Middle Name:
THOMAS
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
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:
1528315280
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
805 ALBERTSON PKWY STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROUSSARD
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70518-4350
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-470-3560
Provider Business Mailing Address Fax Number:
337-837-2551

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
811 D&E ALBERTSON PARKWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROUSSARD
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70518
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-470-3560
Provider Business Practice Location Address Fax Number:
337-837-2551
Provider Enumeration Date:
08/12/2012

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: 207Q00000X , with the licence number:  MD.207240 , 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: 2374991 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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