Healthcare Provider Details

I. General information

NPI: 1376534131
Provider Name (Legal Business Name): CHANTAL SALIM LUTFALLAH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 01/12/2021
Certification Date: 01/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8200 CONSTANTIN BLVD FL 4
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: 225-765-1733
Mailing address:
  • Phone: 225-526-0011
  • Fax: 225-765-9196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number15400R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: