1790705036 NPI number — VICTOR E TEDESCO IV M.D.

Table of content: VICTOR E TEDESCO IV M.D. (NPI 1790705036)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790705036 NPI number — VICTOR E TEDESCO IV M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TEDESCO
Provider First Name:
VICTOR
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
IV
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:
TEDESCO
Provider Other First Name:
VICTOR
Provider Other Middle Name:
E
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
IV
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1790705036
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/16/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5000 AMBASSADOR CAFFERY PKWY
Provider Second Line Business Mailing Address:
PROVINCE BLDG. 14-A
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70508-6984
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-234-7779
Provider Business Mailing Address Fax Number:
337-235-7246

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
155 HOSPITAL DR STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAFAYETTE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70503-2852
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-289-7999
Provider Business Practice Location Address Fax Number:
337-289-7998
Provider Enumeration Date:
07/20/2006

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: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1385794 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 020027313 . This is a "RR MEDICARE" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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