Healthcare Provider Details

I. General information

NPI: 1558540609
Provider Name (Legal Business Name): ILYAS MUNSHI, M.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2007
Last Update Date: 05/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 W MARTIAL AVE
LAFAYETTE LA
70508-6583
US

IV. Provider business mailing address

99 W MARTIAL AVE
LAFAYETTE LA
70508-6583
US

V. Phone/Fax

Practice location:
  • Phone: 337-234-5344
  • Fax: 337-234-5311
Mailing address:
  • Phone: 337-234-5344
  • Fax: 337-234-5311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number14248R
License Number StateLA

VIII. Authorized Official

Name: ILYAS MUNSHI
Title or Position: OWNER
Credential: M.D.
Phone: 337-234-5344