Healthcare Provider Details

I. General information

NPI: 1417346321
Provider Name (Legal Business Name): MARYANNE YACOUB SOURIAL DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2015
Last Update Date: 06/18/2025
Certification Date: 06/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1460 S COLLEGE RD
LAFAYETTE LA
70503-2912
US

IV. Provider business mailing address

1460 S COLLEGE RD
LAFAYETTE LA
70503-2912
US

V. Phone/Fax

Practice location:
  • Phone: 337-703-6431
  • Fax:
Mailing address:
  • Phone: 337-703-6431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number288330
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: