Healthcare Provider Details

I. General information

NPI: 1174152474
Provider Name (Legal Business Name): ALEX RYAN HEATHERLY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2020
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1214 COOLIDGE BLVD
LAFAYETTE LA
70503-2621
US

IV. Provider business mailing address

4212 W CONGRESS ST STE 3100
LAFAYETTE LA
70506-6771
US

V. Phone/Fax

Practice location:
  • Phone: 205-826-3996
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License Number351585
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: