Healthcare Provider Details

I. General information

NPI: 1255474466
Provider Name (Legal Business Name): MYRA LOUISE ANDERSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

879 MILLING AVE
LULING LA
70070-4442
US

IV. Provider business mailing address

40189 PELICAN POINT PKWY.
GONZALES LA
70737-8501
US

V. Phone/Fax

Practice location:
  • Phone: 985-785-2979
  • Fax: 985-785-5051
Mailing address:
  • Phone: 504-491-3124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberMD.06513R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: