Healthcare Provider Details

I. General information

NPI: 1851350151
Provider Name (Legal Business Name): JOSEPH ROBERT BOZZELLE JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 07/07/2022
Certification Date: 07/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 W. ST. MARY BLVD STE 110
LAFAYETTE LA
70506
US

IV. Provider business mailing address

PO BOX 53069
LAFAYETTE LA
70505
US

V. Phone/Fax

Practice location:
  • Phone: 337-233-8887
  • Fax: 337-233-8887
Mailing address:
  • Phone: 337-837-3615
  • Fax: 337-839-8097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number024894
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberMD.024894
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD.024894
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: