Healthcare Provider Details

I. General information

NPI: 1174519045
Provider Name (Legal Business Name): OLEITHA WILSON-RUFFIN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: OLEITHA WILSON M.D.

II. Dates (important events)

Enumeration Date: 09/26/2005
Last Update Date: 12/10/2019
Certification Date: 12/10/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4225 LAPALCO BLVD
MARRERO LA
70072-4324
US

IV. Provider business mailing address

1514 JEFFERSON HWY
NEW ORLEANS LA
70121-2429
US

V. Phone/Fax

Practice location:
  • Phone: 504-391-7337
  • Fax: 504-398-7213
Mailing address:
  • Phone: 504-842-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number025015
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: