Healthcare Provider Details

I. General information

NPI: 1649567678
Provider Name (Legal Business Name): COLE HILLEBRANDT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2011
Last Update Date: 01/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 CORPORATE BLVD
LAFAYETTE LA
70508-3870
US

IV. Provider business mailing address

2305 LEONARD RD
SULPHUR LA
70665-8392
US

V. Phone/Fax

Practice location:
  • Phone: 555-555-5555
  • Fax:
Mailing address:
  • Phone: 337-661-9675
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD.207135
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number005229
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD.207135
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: