Healthcare Provider Details

I. General information

NPI: 1235738634
Provider Name (Legal Business Name): LOUISIANA RETINA A PROFESSIONAL MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2020
Last Update Date: 05/18/2022
Certification Date: 05/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 VETERANS BLVD STE A
DENHAM SPRINGS LA
70726-4723
US

IV. Provider business mailing address

303 VETERANS BLVD STE A
DENHAM SPRINGS LA
70726-4723
US

V. Phone/Fax

Practice location:
  • Phone: 225-242-9729
  • Fax:
Mailing address:
  • Phone: 225-242-9729
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number
License Number State

VIII. Authorized Official

Name: JORDAN BURNHAM
Title or Position: OWNER
Credential: MD
Phone: 225-523-7624