1780786137 NPI number — LUKE SEXTON ELLIOTT JR. PHD

Table of content: LUKE SEXTON ELLIOTT JR. PHD (NPI 1780786137)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780786137 NPI number — LUKE SEXTON ELLIOTT JR. PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLIOTT
Provider First Name:
LUKE
Provider Middle Name:
SEXTON
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
PHD
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:
1780786137
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
119 RIDGEWAY DR
Provider Second Line Business Mailing Address:
SUITE B-1
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70503-3446
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-984-7614
Provider Business Mailing Address Fax Number:
337-984-8696

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
119 RIDGEWAY DR
Provider Second Line Business Practice Location Address:
SUITE B-1
Provider Business Practice Location Address City Name:
LAFAYETTE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70503-3446
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-984-7614
Provider Business Practice Location Address Fax Number:
337-984-8696
Provider Enumeration Date:
09/05/2006

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: 103T00000X , with the licence number:  248 , 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: 20909 . This is a "BLUE CROSS OF LA" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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