Healthcare Provider Details

I. General information

NPI: 1467695247
Provider Name (Legal Business Name): ELIZABETH BERTUCCI ROBERTSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ELIZABETH BRANDON BERTUCCI M.D.

II. Dates (important events)

Enumeration Date: 04/09/2009
Last Update Date: 07/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 PETROLEUM DR LAFAYETTE
LAFAYETTE LA
70508-3880
US

IV. Provider business mailing address

200 PETROLEUM DR LAFAYETTE
LAFAYETTE LA
70508-3880
US

V. Phone/Fax

Practice location:
  • Phone: 337-988-9999
  • Fax: 337-984-7003
Mailing address:
  • Phone: 337-988-9999
  • Fax: 337-984-7003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberMD.205346
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: