Healthcare Provider Details

I. General information

NPI: 1285620690
Provider Name (Legal Business Name): VIKRAM KHOSHOO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2005
Last Update Date: 10/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 MEDICAL CENTER BLVD SUITE SOUTH 650
MARRERO LA
70072-3151
US

IV. Provider business mailing address

1111 MEDICAL CENTER BLVD SOUTH 650, ATTN: HEIDI GWINN
MARRERO LA
70072-3151
US

V. Phone/Fax

Practice location:
  • Phone: 504-349-6504
  • Fax: 504-349-6528
Mailing address:
  • Phone: 504-349-1297
  • Fax: 504-349-1146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number08776R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: