Healthcare Provider Details

I. General information

NPI: 1558333617
Provider Name (Legal Business Name): JOHN MATHEW EDAVETTAL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2006
Last Update Date: 05/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

441 HEYMANN BLVD
LAFAYETTE LA
70503-2611
US

IV. Provider business mailing address

441 HEYMANN BLVD
LAFAYETTE LA
70503-2611
US

V. Phone/Fax

Practice location:
  • Phone: 337-289-8429
  • Fax: 337-289-8431
Mailing address:
  • Phone: 337-289-8429
  • Fax: 337-289-8431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number021589
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number021589
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: