Healthcare Provider Details

I. General information

NPI: 1295738557
Provider Name (Legal Business Name): SHANTIPRAKASH M KEDIA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2005
Last Update Date: 11/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 MEDICAL CENTER BLVD STE S450
MARRERO LA
70072-3151
US

IV. Provider business mailing address

1111 MEDICAL CENTER BLVD STE S450
MARRERO LA
70072-3151
US

V. Phone/Fax

Practice location:
  • Phone: 504-349-6401
  • Fax: 504-349-6444
Mailing address:
  • Phone: 504-349-6423
  • Fax: 504-349-6062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number05114R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: