Healthcare Provider Details

I. General information

NPI: 1619389889
Provider Name (Legal Business Name): STEPHEN GOLDWARE, M.D. A PROFESSIONAL MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2014
Last Update Date: 02/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 SAINT LOUIS ST
LAFAYETTE LA
70506-4538
US

IV. Provider business mailing address

PO BOX 52827
LAFAYETTE LA
70505-2827
US

V. Phone/Fax

Practice location:
  • Phone: 337-456-5500
  • Fax:
Mailing address:
  • Phone: 337-456-5500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberMD.009998
License Number StateLA

VIII. Authorized Official

Name: DR. STEPHEN GOLDWARE
Title or Position: SELF
Credential: M.D.
Phone: 337-456-5500