Healthcare Provider Details

I. General information

NPI: 1679815450
Provider Name (Legal Business Name): RANDALL COREY ROUGELOT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2013
Last Update Date: 07/17/2025
Certification Date: 07/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 METAIRIE RD STE 101
METAIRIE LA
70005-3982
US

IV. Provider business mailing address

1615 METAIRIE RD STE 101
METAIRIE LA
70005-3982
US

V. Phone/Fax

Practice location:
  • Phone: 504-644-4226
  • Fax:
Mailing address:
  • Phone: 504-644-4226
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number25836
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number309295
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: