Healthcare Provider Details

I. General information

NPI: 1730264201
Provider Name (Legal Business Name): MASTOLOGY CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 02/24/2020
Certification Date: 02/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

541 SHADOWS LN STE C
BATON ROUGE LA
70806-6559
US

IV. Provider business mailing address

541 SHADOWS LN STE C
BATON ROUGE LA
70806-6559
US

V. Phone/Fax

Practice location:
  • Phone: 225-755-3070
  • Fax: 225-755-3085
Mailing address:
  • Phone: 225-755-3070
  • Fax: 225-755-3085

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number3326R
License Number StateLA

VIII. Authorized Official

Name: DR. ROBERT LANGE ELLIOTT
Title or Position: DOCTOR
Credential: M.D.
Phone: 225-755-3070