Healthcare Provider Details

I. General information

NPI: 1578884037
Provider Name (Legal Business Name): THOMAS G LATIOLAIS MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2010
Last Update Date: 06/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 HIGHWAY 80
HAUGHTON LA
71037-7425
US

IV. Provider business mailing address

1025 HIGHWAY 80
HAUGHTON LA
71037-7425
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number016345
License Number StateLA

VIII. Authorized Official

Name: THOMAS G LATIOLAIS
Title or Position: OWNER
Credential: MD
Phone: 318-949-0539