Healthcare Provider Details

I. General information

NPI: 1255423992
Provider Name (Legal Business Name): MARVIN DEMENTREOUS CLIFTON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4884 CONSTITUTION AVE STE 1E
BATON ROUGE LA
70808-3324
US

IV. Provider business mailing address

4884 CONSTITUTION AVE STE 1E
BATON ROUGE LA
70808-3324
US

V. Phone/Fax

Practice location:
  • Phone: 225-923-1621
  • Fax: 225-923-1623
Mailing address:
  • Phone: 225-923-1621
  • Fax: 225-923-1623

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number05469R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: