Healthcare Provider Details

I. General information

NPI: 1679578116
Provider Name (Legal Business Name): THOMAS G. LATIOLAIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 06/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 HIGHWAY 80
HAUGHTON LA
71037-7425
US

IV. Provider business mailing address

1908 LANDAU LN
BOSSIER CITY LA
71111-5527
US

V. Phone/Fax

Practice location:
  • Phone: 318-949-0539
  • Fax: 318-949-0759
Mailing address:
  • Phone: 318-426-0206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number016345
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: