1104836790 NPI number — DR. SUSAN F OVELLA MD

Table of content: DR. SUSAN F OVELLA MD (NPI 1104836790)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104836790 NPI number — DR. SUSAN F OVELLA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OVELLA
Provider First Name:
SUSAN
Provider Middle Name:
F
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1104836790
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/28/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5959 S SHERWOOD FOREST BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BATON ROUGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70816-6038
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
985-730-7195
Provider Business Mailing Address Fax Number:
225-765-9196

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
728 W 11TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COVINGTON
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70433-2318
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-765-5777
Provider Business Practice Location Address Fax Number:
225-765-6642
Provider Enumeration Date:
08/08/2006

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: 208000000X , with the licence number:  23081 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 23081 , 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: 1491110 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 08687793 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00148566 . This is a "MEDICARE RAILROAD ID" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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