Healthcare Provider Details

I. General information

NPI: 1316147119
Provider Name (Legal Business Name): KEVIN DALE CHIASSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2007
Last Update Date: 07/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17438 HARD HAT DR
COVINGTON LA
70435-5630
US

IV. Provider business mailing address

626 LA HWY 304
THIBODEAUX LA
70301
US

V. Phone/Fax

Practice location:
  • Phone: 985-249-5600
  • Fax: 985-249-5618
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD.018159
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: