Healthcare Provider Details

I. General information

NPI: 1588856298
Provider Name (Legal Business Name): JUDSON LEIGH PENTON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2007
Last Update Date: 02/26/2025
Certification Date: 02/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 RUE LOUIS XIV
LAFAYETTE LA
70508-5739
US

IV. Provider business mailing address

108 RUE LOUIS XIV
LAFAYETTE LA
70508-5739
US

V. Phone/Fax

Practice location:
  • Phone: 337-235-8007
  • Fax: 337-235-8008
Mailing address:
  • Phone: 337-235-8007
  • Fax: 337-235-8008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD.202273
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number202273
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: