Healthcare Provider Details

I. General information

NPI: 1982732061
Provider Name (Legal Business Name): KELLY THERON CAHILL JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 01/27/2021
Certification Date: 01/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3220 KALISTE SALOOM RD SUITE A
LAFAYETTE LA
70508-7422
US

IV. Provider business mailing address

3220 KALISTE SALOOM RD SUITE A
LAFAYETTE LA
70508-7422
US

V. Phone/Fax

Practice location:
  • Phone: 337-406-9474
  • Fax: 337-406-1027
Mailing address:
  • Phone: 337-406-9474
  • Fax: 337-406-1027

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD.200283
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: