Healthcare Provider Details

I. General information

NPI: 1891823829
Provider Name (Legal Business Name): DPMLGSPRLA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 08/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 HOUMA BLVD SUITE 204
METAIRIE LA
70006-2930
US

IV. Provider business mailing address

3901 HOUMA BLVD SUITE 204
METAIRIE LA
70006-2930
US

V. Phone/Fax

Practice location:
  • Phone: 504-888-9403
  • Fax: 504-888-2895
Mailing address:
  • Phone: 504-888-9403
  • Fax: 504-888-2895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberDPM20007
License Number StateLA

VIII. Authorized Official

Name: MRS. LAUREN GAST
Title or Position: BILLING MANAGER
Credential:
Phone: 985-635-6943