Healthcare Provider Details

I. General information

NPI: 1679872568
Provider Name (Legal Business Name): MARK TRAHAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2011
Last Update Date: 01/15/2025
Certification Date: 01/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3704 NORTH BLVD STE 1
ALEXANDRIA LA
71301-3673
US

IV. Provider business mailing address

1800 RYAN ST STE 105
LAKE CHARLES LA
70601-6078
US

V. Phone/Fax

Practice location:
  • Phone: 225-773-4726
  • Fax:
Mailing address:
  • Phone: 337-439-4706
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number304164
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: