Healthcare Provider Details

I. General information

NPI: 1366439457
Provider Name (Legal Business Name): PETER BOZNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 03/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1214 COOLIDGE BLVD
LAFAYETTE LA
70503-2621
US

IV. Provider business mailing address

PO BOX 52087
LAFAYETTE LA
70505-2087
US

V. Phone/Fax

Practice location:
  • Phone: 337-289-7991
  • Fax:
Mailing address:
  • Phone: 337-261-5151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number14014R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: