1629244132 NPI number — DR. DEREGAL FAY BURBANK MD

Table of content: DR. DEREGAL FAY BURBANK MD (NPI 1629244132)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629244132 NPI number — DR. DEREGAL FAY BURBANK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BURBANK
Provider First Name:
DEREGAL
Provider Middle Name:
FAY
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:
1629244132
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/31/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
55 YELLOWSTONE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW ORLEANS
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70131
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-270-8370
Provider Business Mailing Address Fax Number:
504-392-0359

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 MEADOWCREST ST.
Provider Second Line Business Practice Location Address:
SUITE 245
Provider Business Practice Location Address City Name:
GRETNA
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70056
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
504-391-7690
Provider Business Practice Location Address Fax Number:
504-391-7625
Provider Enumeration Date:
05/05/2008

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:  016402 , 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: 1324230 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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