Healthcare Provider Details

I. General information

NPI: 1619960432
Provider Name (Legal Business Name): BAHRAM SADEGHPOUR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2005
Last Update Date: 01/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

843 MILLING AVE
LULING LA
70070-4442
US

IV. Provider business mailing address

843 MILLING AVE
LULING LA
70070-4442
US

V. Phone/Fax

Practice location:
  • Phone: 985-785-5852
  • Fax: 985-785-5811
Mailing address:
  • Phone: 985-785-5800
  • Fax: 985-785-5811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number07643R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: