MEDICARE: GRAFTON DERMATOLOGY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332900000X	Non-Pharmacy Dispensing Site	022623	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	1932400	OTHER	OTHER ID NUMBER-COMMERCIAL NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1710063391
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRAFTON DERMATOLOGY

Provider Business Mailing Address
First Line	:	327 BAYOU GARDENS BLVD
Second Line	:
City	:	HOUMA
State	:	LA
Zip	:	70364-1434
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	327 BAYOU GARDENS BLVD
Second Line	:
City	:	HOUMA
State	:	LA
Zip	:	70364-1434
Country	:	US
Telephone Number	:	985-876-5000
Fax Number	:	985-876-5280

Authorized Official
Title or Position	:	OFF MGR
Name	:	ANN BOURGEOIS
Credential	:
Telephone Number	:	978-876-5000

Provider Enumeration Date	:	10/27/2006
Last Update Date	:	08/22/2020

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Directions to “GRAFTON DERMATOLOGY ” Practice Location

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