Healthcare Provider Details

I. General information

NPI: 1629712153
Provider Name (Legal Business Name): JACOB ARDOIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2022
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1980 TYBEE LN
LAKE CHARLES LA
70605-4173
US

IV. Provider business mailing address

PO BOX 4765
LAKE CHARLES LA
70606-4765
US

V. Phone/Fax

Practice location:
  • Phone: 337-447-0963
  • Fax: 337-477-1912
Mailing address:
  • Phone: 337-477-0963
  • Fax: 337-477-1912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number349737
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: