Healthcare Provider Details

I. General information

NPI: 1316986177
Provider Name (Legal Business Name): THOMAS V BERTUCCINI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 12/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 W SAINT MARY BLVD SUITE 306
LAFAYETTE LA
70506-3568
US

IV. Provider business mailing address

601 W SAINT MARY BLVD SUITE 306
LAFAYETTE LA
70506-3568
US

V. Phone/Fax

Practice location:
  • Phone: 337-235-0933
  • Fax: 337-269-1328
Mailing address:
  • Phone: 337-235-0933
  • Fax: 337-269-1328

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number04479R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: