Healthcare Provider Details

I. General information

NPI: 1154322923
Provider Name (Legal Business Name): JIBRAN ELIAS ATWI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2005
Last Update Date: 11/05/2021
Certification Date: 11/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 YOUNGSVILLE HWY SUITE 100
LAFAYETTE LA
70508-5173
US

IV. Provider business mailing address

2308 E MAIN ST SUITE G
NEW IBERIA LA
70560-4041
US

V. Phone/Fax

Practice location:
  • Phone: 337-330-0031
  • Fax: 337-330-0059
Mailing address:
  • Phone: 337-367-2001
  • Fax: 337-365-3050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number10447R
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number10447R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: