1851404453 NPI number — KEITH J LANDRY M.D.

Table of content: KEITH J LANDRY M.D. (NPI 1851404453)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851404453 NPI number — KEITH J LANDRY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LANDRY
Provider First Name:
KEITH
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1851404453
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/05/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5478
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
THIBODAUX
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70302-5478
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
985-447-5500
Provider Business Mailing Address Fax Number:
985-449-2535

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
114 HIGHWAY 403
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PAINCOURTVILLE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70390
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
985-369-3514
Provider Business Practice Location Address Fax Number:
985-252-1400
Provider Enumeration Date:
08/16/2006

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:  017704 , 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: 300093737 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: 1348643 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com