Healthcare Provider Details

I. General information

NPI: 1932320983
Provider Name (Legal Business Name): MICHELE KAUTZMAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 10/15/2020
Certification Date: 10/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

441 WALL BLVD
GRETNA LA
70056-7723
US

IV. Provider business mailing address

PO BOX 3146
GRETNA LA
70054-3146
US

V. Phone/Fax

Practice location:
  • Phone: 504-361-9800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License NumberMD205176
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD.205176
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD.205176
License Number StateLA
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2007-00351
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: