Healthcare Provider Details

I. General information

NPI: 1538129135
Provider Name (Legal Business Name): MARY T KILLACKEY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2006
Last Update Date: 02/28/2025
Certification Date: 02/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4320 HOUMA BLVD
METAIRIE LA
70006-2961
US

IV. Provider business mailing address

1430 TULANE AVE # 2682
NEW ORLEANS LA
70112-2632
US

V. Phone/Fax

Practice location:
  • Phone: 504-988-5344
  • Fax:
Mailing address:
  • Phone: 504-988-2317
  • Fax: 504-988-7510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License NumberMD.201122
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: