Healthcare Provider Details

I. General information

NPI: 1629244132
Provider Name (Legal Business Name): DEREGAL FAY BURBANK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2008
Last Update Date: 07/31/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 MEADOWCREST ST. SUITE 245
GRETNA LA
70056
US

IV. Provider business mailing address

55 YELLOWSTONE DR
NEW ORLEANS LA
70131
US

V. Phone/Fax

Practice location:
  • Phone: 504-391-7690
  • Fax: 504-391-7625
Mailing address:
  • Phone: 225-270-8370
  • Fax: 504-392-0359

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number016402
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: