Healthcare Provider Details

I. General information

NPI: 1962559740
Provider Name (Legal Business Name): PEDIATRIC CARDIOLOGY OF SOUTHWEST LOUISIANA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 04/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2005 SOUTHWOOD DR
LAKE CHARLES LA
70605-4139
US

IV. Provider business mailing address

2005 SOUTHWOOD DR
LAKE CHARLES LA
70605-4139
US

V. Phone/Fax

Practice location:
  • Phone: 337-562-2293
  • Fax: 337-562-1469
Mailing address:
  • Phone: 337-562-2293
  • Fax: 337-562-1469

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License NumberMD.12869R
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License NumberMD.203075
License Number StateLA

VIII. Authorized Official

Name: MUDAR M KATTASH
Title or Position: OWNER
Credential: M.D.
Phone: 337-562-2293