Healthcare Provider Details

I. General information

NPI: 1942316450
Provider Name (Legal Business Name): BRYAN BERTUCCI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 03/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

843 MILLING AVE
LULING LA
70070-4442
US

IV. Provider business mailing address

7718 W JUDGE PEREZ DR
ARABI LA
70032-1919
US

V. Phone/Fax

Practice location:
  • Phone: 985-785-5851
  • Fax: 504-278-4692
Mailing address:
  • Phone: 504-271-8952
  • Fax: 504-278-4692

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number015628
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: