Healthcare Provider Details

I. General information

NPI: 1861425324
Provider Name (Legal Business Name): JALAL JOUDEH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 12/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 W 4TH ST
DEQUINCY LA
70633-3301
US

IV. Provider business mailing address

601 W 4TH ST P.O. BOX 866
DEQUINCY LA
70633-3301
US

V. Phone/Fax

Practice location:
  • Phone: 337-786-6161
  • Fax: 337-786-7999
Mailing address:
  • Phone: 337-786-6161
  • Fax: 337-786-7999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number11027R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: