Healthcare Provider Details

I. General information

NPI: 1801897459
Provider Name (Legal Business Name): JAMES C INGRAM JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2005
Last Update Date: 04/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 KALISTE SALOOM RD BLDG 2 STE 201
LAFAYETTE LA
70508-6186
US

IV. Provider business mailing address

501 DR MICHAEL DEBAKEY DR
LAKE CHARLES LA
70601-5724
US

V. Phone/Fax

Practice location:
  • Phone: 337-534-8346
  • Fax: 337-534-8396
Mailing address:
  • Phone: 337-312-8360
  • Fax: 337-312-6708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberMD 011266
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: