Healthcare Provider Details

I. General information

NPI: 1083840888
Provider Name (Legal Business Name): KYLE JACOB DEGEYTER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2009
Last Update Date: 08/10/2023
Certification Date: 08/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 AMBASSADOR CAFFERY PKWY
LAFAYETTE LA
70508-6917
US

IV. Provider business mailing address

4801 AMBASSADOR CAFFERY PKWY
LAFAYETTE LA
70508-6917
US

V. Phone/Fax

Practice location:
  • Phone: 337-470-2000
  • Fax:
Mailing address:
  • Phone: 337-470-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD.204796
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberMD.204796
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: