Healthcare Provider Details

I. General information

NPI: 1114217189
Provider Name (Legal Business Name): JUAN MEDAURA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2011
Last Update Date: 06/01/2022
Certification Date: 06/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3525 PRYTANIA ST STE 402
NEW ORLEANS LA
70115-3585
US

IV. Provider business mailing address

3600 PRYTANIA ST STE 35
NEW ORLEANS LA
70115-3678
US

V. Phone/Fax

Practice location:
  • Phone: 504-648-2520
  • Fax: 504-897-2939
Mailing address:
  • Phone: 504-897-8412
  • Fax: 504-249-5311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number330645
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number24487
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: