Healthcare Provider Details

I. General information

NPI: 1831123132
Provider Name (Legal Business Name): GEORGE THOMAS WATERFALLEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 01/14/2025
Certification Date: 01/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

323 WEST WALNUT
BASTROP LA
71220
US

IV. Provider business mailing address

200 CORPORATE BLVD STE 201
LAFAYETTE LA
70508-3870
US

V. Phone/Fax

Practice location:
  • Phone: 800-893-9698
  • Fax:
Mailing address:
  • Phone: 800-893-9698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number014605
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberMD.014605
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: