Healthcare Provider Details

I. General information

NPI: 1366421562
Provider Name (Legal Business Name): MARIO KAKAZU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2006
Last Update Date: 06/30/2021
Certification Date: 06/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2552 WILLIAMS BLVD
KENNER LA
70062-5538
US

IV. Provider business mailing address

PO BOX 2490
MARRERO LA
70073-2490
US

V. Phone/Fax

Practice location:
  • Phone: 504-463-3002
  • Fax:
Mailing address:
  • Phone: 504-762-8909
  • Fax: 504-328-0899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number05311R
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberMD.05311R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: