Healthcare Provider Details

I. General information

NPI: 1932595873
Provider Name (Legal Business Name): CHARLES EDWARD DEDEAUX JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2015
Last Update Date: 10/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7373 PERKINS RD
BATON ROUGE LA
70808
US

IV. Provider business mailing address

7373 PERKINS RD
BATON ROUGE LA
70808-4373
US

V. Phone/Fax

Practice location:
  • Phone: 225-769-4044
  • Fax: 225-246-9116
Mailing address:
  • Phone: 225-246-9790
  • Fax: 225-246-9100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number308373
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: