Healthcare Provider Details

I. General information

NPI: 1902161177
Provider Name (Legal Business Name): KYLE JUDE PONTIFF MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2012
Last Update Date: 08/05/2021
Certification Date: 08/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8200 CONSTANTIN BLVD FL 1
BATON ROUGE LA
70809-3481
US

IV. Provider business mailing address

5959 S SHERWOOD FOREST BLVD
BATON ROUGE LA
70816-6038
US

V. Phone/Fax

Practice location:
  • Phone: 225-765-5500
  • Fax: 225-374-0501
Mailing address:
  • Phone: 225-526-0011
  • Fax: 225-765-9191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberGETP.200986
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number54631
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License Number2020020214
License Number StateMO
# 4
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number207988
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: