Healthcare Provider Details

I. General information

NPI: 1881696078
Provider Name (Legal Business Name): GHIATH M MIKDADI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 05/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16033 DOCTORS BLVD
HAMMOND LA
70403-1479
US

IV. Provider business mailing address

16033 DOCTORS BLVD
HAMMOND LA
70403-1479
US

V. Phone/Fax

Practice location:
  • Phone: 985-974-9278
  • Fax: 985-542-6341
Mailing address:
  • Phone: 985-974-9278
  • Fax: 985-542-6341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number11934R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: