Healthcare Provider Details

I. General information

NPI: 1518965102
Provider Name (Legal Business Name): MARY ANGELA MAYEUX MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 09/19/2019
Certification Date:
Deactivation Date: 03/21/2006
Reactivation Date: 03/27/2006

III. Provider practice location address

4212 W CONGRESS ST STE 3100
LAFAYETTE LA
70506-6771
US

IV. Provider business mailing address

PO BOX 919229
DALLAS TX
75391-9229
US

V. Phone/Fax

Practice location:
  • Phone: 337-703-3201
  • Fax: 337-703-3202
Mailing address:
  • Phone: 337-289-8944
  • Fax: 337-571-0030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number019577
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: