1538138763 NPI number — DR. CLAYTON COLLINS COON M.D.

Table of content: DR. CLAYTON COLLINS COON M.D. (NPI 1538138763)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538138763 NPI number — DR. CLAYTON COLLINS COON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COON
Provider First Name:
CLAYTON
Provider Middle Name:
COLLINS
Provider Name Prefix Text:
DR.
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:
1538138763
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/31/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
611 GRAMMONT ST.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONROE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71201-7516
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-325-2634
Provider Business Mailing Address Fax Number:
318-812-1205

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
102 THOMAS RD.
Provider Second Line Business Practice Location Address:
SUITE 114
Provider Business Practice Location Address City Name:
WEST MONROE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71291-7365
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-812-3303
Provider Business Practice Location Address Fax Number:
318-812-3304
Provider Enumeration Date:
03/17/2006

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: 207RG0100X , with the licence number:  021320 , 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: 1680435 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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