Healthcare Provider Details

I. General information

NPI: 1285635508
Provider Name (Legal Business Name): JOAN GRODE MARSHAK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 02/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 AMBASSADOR CAFFERY PKWY
LAFAYETTE LA
70508-6902
US

IV. Provider business mailing address

4600 AMBASSADOR CAFFERY PKWY
LAFAYETTE LA
70508-6902
US

V. Phone/Fax

Practice location:
  • Phone: 337-521-9113
  • Fax: 337-261-2697
Mailing address:
  • Phone: 337-521-9113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZN0500X
TaxonomyNeuropathology Physician
License Number06781R
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number06781R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: