Healthcare Provider Details

I. General information

NPI: 1548327372
Provider Name (Legal Business Name): MAMDOUH GIRGIS MICKAIL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 03/20/2025
Certification Date: 03/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 N 16TH ST
MER ROUGE LA
71261-9726
US

IV. Provider business mailing address

PO BOX 792
BASTROP LA
71221-0792
US

V. Phone/Fax

Practice location:
  • Phone: 318-239-8010
  • Fax: 318-647-3909
Mailing address:
  • Phone: 318-283-8887
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number07043R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: