Healthcare Provider Details

I. General information

NPI: 1104816115
Provider Name (Legal Business Name): JOHN E NYBOER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2005
Last Update Date: 04/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10101 PARK ROWE AVE SUITE 200
BATON ROUGE LA
70810-1686
US

IV. Provider business mailing address

PO BOX 98509
BATON ROUGE LA
70884-9509
US

V. Phone/Fax

Practice location:
  • Phone: 225-769-2200
  • Fax: 225-768-2185
Mailing address:
  • Phone: 225-769-2200
  • Fax: 225-768-2185

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number10309R
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number10309R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: